Management Of Recurrent Tracheoesophageal Fistula Research Articles

Endoscopic management of recurrent tracheoesophageal fistula with trichloroacetic acid in pediatric patients.

Surgical repair of recurrent tracheoesophageal fistula has a high risk of complications. Therefore, various endoscopic techniques have been used to avoid complications. To understand the usefulness of trichloroacetic acid endoscopic application for the treatment of recurrent tracheoesophageal fistula. An observational, descriptive, retrospective, case-series-based study was carried out in a tertiary pediatric hospital. Records of patients with recurrent tracheoesophageal fistula from 2015 to 2021 were reviewed. All patients within this period underwent brushing and trichloroacetic acid application. Mean time of recurrent tracheoesophageal fistula occurrence was 4.8 months (range: 1-19.2). Two patients had a small fistula (less than 4 mm), three patients had a medium fistula (4 mm), and two patients had a large fistula (more than 4 mm). Mean sessions for fistula closure were 2.2 (range: 1-4). Mean time between procedures was 22 days (range: 14-30). Mean follow-up since fistula closure confirmation was 33 months (range: 9-72), during which no recurrences were noted. Endoscopic management of recurrent transesophageal fistula with trichloroacetic acid is a safe and effective procedure. Brushing and trichloroacetic acid combined improve success rates. Fistulas over 4 mm in diameter require more procedures. However, a larger patient cohort and a longer follow-up period are needed to confirm this.

The multidisciplinary management of recurrent tracheoesophageal fistula after esophageal atresia: Experience with 135 cases from a tertiary center

Background & aimsRecurrent tracheoesophageal fistula (rTEF) after esophageal atresia requires complex management across different specialties. This study reviews our experience and discusses a multidisciplinary (MDT) approach adopted in the past 4 years. MethodsWe reviewed the medical records of 100 patients with rTEF managed by an MDT approach (post-MDT group) from 2016 to 2019. These cases were compared to a historical group of 35 patients with rTEF from 2012 to 2015 (pre-MDT group). ResultsOf the 135 patients with rTEF, 124 were referred from other hospitals. Preoperative examination found tracheomalacia in 23 patients, vocal fold immobility in 19 patients, and laryngomalacia in five patients. The incidence of postoperative anastomotic leak, anastomotic stricture, and repeat recurrences was 28.1%, 23.0%, and 8.9%, respectively. The overall mortality rate was 4.4%. No statistical difference in postoperative complications was noted between the two groups. The duration of stay in the pediatric intensive care unit (P = 0.038), the duration of intubation (P = 0.049), the postoperative hospital stay (P = 0.011), and the total length of hospital stay (P = 0.001) were significantly lower in the post-MDT group. Mid-term follow-up showed 23 patients had pathological gastroesophageal reflux. Five of them underwent fundoplication and recovered. ConclusionThe MDT approach by fostering coordination of surgical, medical, radiological, and nutritional management is beneficial in the management of rTEF and leads to a satisfactory outcome .

DOZ047.121: Usefulness of conservative treatment in recurrent tracheoesophageal fistula in children

Abstract Introduction Recurrent tracheoesophageal fistula (TEF) is a challenging complication in children with repaired esophageal atresia (EA). Thoracotomy, with surgical repair, is the traditional therapeutic approach, however it is often associated with a significant morbidity and technical difficulty. Endoscopic techniques, from the tracheal and/or esophageal side, have recently been proposed as a primary treatment, in order to prevent reoperation especially in previously operated fields. Aim of this retrospective study is to present our experience as Tertiary Care Center and Referral Center for EA, on the endoscopic management of recurrent TEF in children with repaired EA. Method This is a retrospective study conducted on children with repaired EA referred at Bambino Gesù Children's Hospital from January 2009 to January 2019. Demographic and clinical details, including type of EA, presence of fistula, concomitant malformations, endoscopic evaluation, number and kind of treatments, performed were collected. Results We identified 171 patients with EA, 15 type 1 (9%), 7 type 2 (4%), 140 type 3 (82%), 6 type 4 (3%), 3 type 5 (2%). Among patients with TEF, 11/156 (7%- M:F/6:5) presented with a TEF recurrence. Among the latter, 5 (45.4%) were patients with concomitant malformation (2 VACTER, 2 anorectal malformation, 1 Down syndrome, cardiac abnormalities, and hypothyroidism). All patients with TEF recurrence presented with symptoms, such as chronic cough, vomit, bronchitis, recurrent pneumonia, and failure to thrive. All patients underwent endoscopic evaluation both from digestive and tracheal side. Six (6/11–54.5%) patients underwent surgery, 5 patients (5/11–45.4%) were treated with endoscopic transtracheal fibrin glue injection after brushing that was successful in two patients (2/5–40%), one patient needed a retreatment. These patients maintained successful closure after treatment confirmed at endoscopic follow-up. Remaining three patients needed surgical approach during follow-up. Conclusion Endoscopic repair of recurrent TEF has proved safe and effective in the literature as an alternative to a second open thoracotomy/surgical repair. In our series, although in two cases, it represented a valid alternative to surgery. We suggest that it is worthy to try a conservative approach before surgery.

Management of recurrent tracheoesophageal fistula after esophageal atresia and follow-up.

Recurrent tracheoesophageal fistula (rTEF) is a complex complication after the repair of esophageal atresia (EA) and remains a challenge because of difficulties in preoperative management and the substantial rates of mortality and morbidity after reoperation. By reviewing a single institution's experience in the management of rTEF and assessing the outcome, we aimed to provide an optimal approach for managing rTEF and to evaluate growth and feeding problems after reoperations. The medical records of 35 patients with rTEF treated at a single institution from June 2012 to December 2015 were reviewed, and follow-up data were collected from all survivors. The diagnosis of rTEF was made using a modified esophagram in 32 of 35 patients. Before reoperation, all patients received continuous aspiration to prevent reflux and aspiration pneumonia by placing two nasogastric tubes at the level of the fistula and into the stomach, and they received enteral nutrition through a jejunal feeding tube. Thirty-five patients received a total of 41 reoperations, including 12 operations of fistula resection, 28 reanastomosis, and 1 esophageal replacement. The incidence of postoperative anastomotic leak (AL), anastomotic stricture (AS), and repeat recurrences was 40.0%, 17.1%, and 11.4%, respectively. The mortality rate was 8.6%. All survivors achieved full oral intake. Mid-term follow-up (median of 18 months) revealed that 7 (21.9%) presented prolonged meal time, 6 (18.8%) had feeding refusal, 8 (25.0%) experienced coughing during feeding, and 7 (21.9%) had vomiting during feeding. According to the growth data, 5 survivors (15.6%) presented with growth retardation, including stunting (n=1), wasting (n=2), and underweight (n=2). The modified esophagram is an effective and reliable method for diagnosing rTEF. Optimized preoperative management and surgical techniques lead to a satisfactory outcome. Nevertheless, nutritional evaluation and feeding guidance by a nutritionist after reoperation are recommended.

Redo esophageal surgery: the diagnosis and management of recurrent tracheoesophageal fistula

This article presents a 30-year review of 38 recurrent tracheoesophageal fistulas. The initial 26 cases were presented in 2009 at the annual meeting of the British Association of Pediatric Surgeons and the European Association of Pediatric Surgeons Joint Conference and published in the Journal of Pediatric Surgery (Bruchet al. J Pediatr Surg 45:337-340, 2010). In the initial cohort of 26 patients, 18 had a leak after their primary operation and 22 had respiratory symptoms leading to the discovery of the recurrent fistula. The diagnosis was made by a contrast study in 24. The repairs entailed replacing a catheter through the fistula, separating the trachea and esophagus completely using sharp dissection and placing vascularized tissue, either pleura or pericardium between the suture lines. Postoperative complications included seven anastomotic leaks, four strictures and three recurrent fistulas. Long-term follow-up (median of 84months) showed that 21 took all of their nutrition by mouth, three were tube fed and two required a combination of both. Of the 23 patients with growth chart data, 16 fell into the first quartile of the growth chart, whereas none fell between the 75th and 100th percentile. In conclusion, this initial series of 26 patients along with the updated additional series of 12 patients is the largest series thus far reported in the literature. All 38 patients represent the characteristics of recurrent tracheoesophageal fistulas, including techniques to make the diagnosis and to provide a secure closure of the fistula, and the long-term outcomes of these patients.

Multiple anastomotic complications following repair of oesophageal atresia with tracheoesophageal fistula: A report of two cases

This report describes the clinical course and management of two children with multiple anastomotic complications following primary repair of oesophageal atresia (EA) with distal tracheoesophageal fistula (TEF). These included anastomotic leak and stricture, oesophageal perforation during antegrade dilatation, and finally a recurrent fistula between the oesophagus and the tracheo-bronchial tree. Ultimately, after multiple operative interventions, a successful outcome was achieved in both patients with preservation of the native oesophagus. The anastomotic complications following primary repair of EA with TEF are discussed, with special reference to difficulties in the management of recurrent TEF.

Endoscopic management of recurrent tracheoesophageal fistula with trichloroacetic acid chemocauterization: A preliminary report

Purpose Open repair with a second thoracotomy is technically challenging and has a high risk of complications for the treatment of a recurrent tracheoesophageal fistula (RTEF). Therefore, less invasive endoscopic techniques have been developed. Here, we report on the chemocauterization with trichloroacetic acid (TCA) technique for endoscopic management of RTEF. Methods Three patients who had an open repair with thoracotomy for congenital tracheoesophageal fistula and were diagnosed with RTEF were included in this study. Rigid ventilating bronchoscopy with telescopic magnification was used to evaluate and manage the RTEF. After identification of the fistula opening, a 50% TCA-soaked small cotton ball was applied in the opening 3 times during each session. Results The mean number of procedures was 3.3, and the fistulae were closed in all cases. Closure of the fistula was confirmed by esophagogram and/or bronchoscopy. There were no postoperative complications. Conclusion The results of this study showed that chemocauterization with TCA can be safe and effective for the management of RTEF.

Endoscopic management of recurrent tracheoesophageal fistula

Recurrent tracheoesophageal fistulas (RTEFs) remain a therapeutic challenge because open surgical approaches have been associated with substantial rates of morbidity, mortality, and repeat recurrences. Recently, endoscopic techniques for the repair of RTEF have provided an alternative approach with the potential for improved surgical outcomes. However, previous reports have been limited by small patient numbers and variations in technique. By examining a single institution's experience and performing a systematic review of previously published results, we aimed to identify an optimal approach to managing RTEF endoscopically. Retrospective chart review of patients undergoing endoscopic management of RTEF at a single tertiary care institution was performed. Medline search and summated analysis of previously published cases of endoscopically treated RTEF from 1975 to 2007 was conducted. Four patients with RTEF were identified and selected for endoscopic repair at our institution from 2003 to 2007 (mean age, 11.5 months). Under endoscopic guidance, fistula tracts were de-epithelialized with a Bugbee fulgurating diathermy electrode (5-15 W) and then sealed with fibrin glue (Tisseel with added aprotinin). Closure of RTEF was successful in 3 patients after a single attempt. One revision was required after inadvertent recannulation of the tract with an emergent tracheostomy tube change. No patient has evidence of recurrence (mean follow-up, 16 months). In 15 articles of endoscopically repaired RTEF, 37 cases have been reported from 1975 until present. In general, 3 approaches to endoscopic repair have been explored. Analysis of all reported cases in the literature and results from our patient series suggests that endoscopic techniques designed to both de-epithelialize the fistula tract and seal with fibrin glue have the best chance for cure after a single attempt. Patients with long, thin, and small diameter fistula who have enough distal trachea to accommodate a postoperative cuffed ventilating tube beyond the fistula are ideal candidates for endoscopic repair. In select patients, endoscopic management of RTEF using Bugbee cautery and tissue adhesives can reduce morbidity and recurrence associated with open approaches and alternative endoscopic techniques.

Median sternotomy and use of a pedicled sternocleidomastoid muscle flap in the management of recurrent tracheoesophageal fistula

Recurrent tracheoesophageal fistula may complicate primary repair of congenital tracheoesophageal fistula. Standard treatment involves repair via a right lateral thoracotomy and use of adjacent soft tissues to separate the suture lines of the fistulous openings. The authors describe an alternative approach via a median sternotomy, which improves access, reduces the operating time required to identify the recurrent fistula, and enables the use of a pedicled sternocleidomastoid muscle flap to decrease the risk of refistulization.

The use of pericardium for the management of recurrent tracheoesophageal fistula

Correction of congenital esophageal atresia and tracheoesophageal fistula (TEF) with either a primary or staged repair may result in recurrence of the TEF, most often at the site of esophageal anastomosis. Definitive operative repair of a recurrent TEF involves isolation and resection of the fistula with closure of the tracheal and esophageal defects. A technique is described, whereby mobilization of a vascularized pedicle of pericardium allows further enhancement of the standard repair of a recurrent TEF. The vascularized pedicle of pericardium serves to isolate the tracheal and esophageal suture lines from each other, as well as aid in sealing leaks at either or both suture lines. This may dramatically reduce the incidence of second recurrences and lower the overall operative mortality, reportedly as high as 59%.