Recurrent Tracheoesophageal Fistula Research Articles

Management of Recurrent Tracheoesophageal Fistulas: A Systematic Review

The management of a recurrent tracheoesophageal fistula (RTEF) includes either open surgery (OS) or an endoscopic treatment (ET); the ideal option is unclear. We aim to comparatively review all published treatment options, and outcomes, for managing RTEF. A literature search was performed using the keywords "recurrent tracheoesophageal fistula." All English language articles describing the management of RTEF in children were reviewed. A synthesis of the relevant data is presented in a descriptive form due to the heterogeneity of the included articles. A total of 44 papers between 1955 and 2013 described 165 patients; 57 ET and 108 OS. Of the 57 ET patients, there was an 84% success rate compared with 93.5% of 108 OS patients; the failed ET cases were all successfully treated by OS. The refistulation rate after OS was 21% and an average of 1.1 (range 1-2) procedures were required. After ET, the refistulation rate was 63% and an average of 2.1 (range 1-6) treatments were required for success; these results were reported after a maximum follow-up of 9 years and 23 years for ET and OS, respectively. The major complications after OS were 17 (16%) leaks and 4 (3.7%) deaths, while for ET 3 (5%) suffered respiratory distress postoperatively and there was 1 (1.7%) death. OS for RTEF has a low morbidity and mortality, a higher success rate, and requires fewer treatments than an endoscopic repair. The ideal ET is undecided but it remains a viable alternative provided treatment failures are anticipated and prompt redo treatments initiated to prevent ongoing respiratory morbidity.

Esophageal atresia: a critical review of management at a single center in Algeria

The purpose was to study the outcomes and factors affecting the survival of esophageal atresia in our center. A retrospective analysis of 86 cases of esophageal atresia (EA) over a 10-year period was performed with 46 boys and 42 girls. Demographic data, birth weight, gestational age, consanguinity, incidence of associated anomalies, place of delivery, history of feeding, and outcomes were studied. EA with distal tracheoesophageal fistula (TEF) was the commonest type with 58/86 (67%). The percentage of patients with at least one associated anomaly was 52/86 (60%), with 7/86 (8%) who are from consanguineous parents; most commonly associated anomalies were cardiac 13/86 (15%). The average gestational age and birth weight were 36 ± 2 weeks and 2300 ± 570 g, respectively. Survival rates for the patients according to the Waterston classification was 80% in group A, 58% in group B, and 25% in group C (three patients died before surgery). Prematurity, the gap between the two ends of the esophagus, and preoperative respiratory status were the most significant factors affecting the survival. Late complication of EA/TEF include respiratory symptoms, especially in the first year, associating tracheomalacia and bronchopulmonary infections in about 24/45 (53%), recurrence of TEF 3/45 (7%), esophageal stricture 26/45 (58%), and gastroesophageal reflux 22/45 (49%). The high incidence of delayed diagnosis, low birth weight, and lack of advanced neonatological management are important contributory factors to the poor outcome. The frequency of late complications highlights the need for multidisciplinary clinics to follow these children's.

Endoscopic stenting and clipping for anastomotic stricture and persistent tracheoesophageal fistula after surgical repair of esophageal atresia in an infant.

Anastomotic stricture (AS) and recurrent tracheoesophageal fistula (TEF) are two complications of surgical repair of esophageal atresia (EA). Therapeutic endoscopic modalities include stenting, tissue glue, and clipping for TEF and endoscopic balloon dilation bougienage and stenting for esophageal strictures. We report herein a two-month infant with both EA and TEF who benefited from a surgical repair for EA, at the third day of life. Two months later he experienced deglutition disorders and recurrent chest infections. The esophagogram showed an AS and a TEF confirmed with blue methylene test at bronchoscopy. A partially covered self-expanding metal type biliary was endoscopically placed. Ten weeks later the stent was removed. This allows for easy passage of the endoscope in the gastric cavity but a persistent recurrent fistula was noted. Instillation of contrast demonstrated a fully dilated stricture but with a persistent TEF. Then we proceeded to placement of several endoclips at the fistula site. The esophagogram confirmed the TEF was obliterated. At 12 months of follow-up, he was asymptomatic. Stenting was effective to alleviate the stricture but failed to treat the TEF. At our knowledge this is the second case of successful use of endoclips placement to obliterate recurrent TEF after surgical repair of EA in children.

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.

Morbidity and mortality in esophageal atresia and tracheoesophageal fistula

Background: The outcome of newborns with esophageal atresia (EA) and tracheoesophageal fistula (TEF) has improved considerably. At present, the overall survival rates reported from developed countries are between 85 and 95%. This, however, is not the case from developing countries, where several factors contribute to higher morbidity and mortality rates. This study is an analysis of our experience with 158 patients of EA and TEF, with emphasis on factors contributing to morbidity and mortality. Patients and methods: This is a retrospective study of 158 patients with EA and TEF treated over a period of 20 years (between January 1992 and December 2011). Their records were reviewed, the study period was divided into two equal periods, and the results were analyzed accordingly. Results: A total of 158 patients (89 boys and 69 girls) with EA/TEF were treated. Their mean birth weight was 2.4 kg (700–3800 g). Their ages at diagnosis ranged from newborn to 8 months. Their gestational age ranged from 32 weeks to 41 weeks. Contrast study was used in 45 (28.5%) patients. Aspiration pneumonia was detected in 34.8% patients. The distribution of the number of patients according to the type of EA/TEF was as follows: 132 (83.5%) patients had EA with distal TEF, 14 (8.9%) had pure EA, five (3.2%) had EA with proximal and distal TEF, five (3.2%) had H-type TEF, and two (1.3%) had EA with proximal TEF. Forty-one (22.2%) patients had long-gap EA/TEF. Associated anomalies were seen in 82 (51.9%) patients, and 17 (10.8%) patients had severe anomalies. The postoperative complications included: anastomotic leak in 20 patients (12.7%), stricture in 22 (13.9%),gastroesophageal reflux in 18 (11.4%), tracheomalacia in two (1.3%), and recurrent TEF in one (0.6%). However, there was a marked decrease both in mortality and morbidity during the second period of the study. In our study, the overall mortality rate was 20.9%, but if those with severe associated anomalies were excluded, our postoperative mortality rate was 8.4%. Sepsis was the main cause of death. Conclusion: This is a relatively large series from a developing country. Although our postoperative complication rates were similar to those from developed countries, the overall mortality was higher. There was, however, a marked improvement during the second period of the study. This is attributed to a better understanding, early diagnosis, prompt referral, and better surgical techniques. Prematurity, sepsis, and associated severe malformations were the main causes of death. Once major anomalies responsible for death were excluded, our postoperative mortality rate was 8.4%. Sepsis continues to be a major cause of death, and several factors contribute to this, including prematurity and delayed diagnosis with increased incidence of aspiration pneumonia. To decrease the mortality rate, these factors should be addressed, and every effort should be made to overcome them. Patients with long-gap EA/TEF continue to be a management challenge, and every attempt should be made to preserve the native esophagus. Delayed primary repair and/or esophageal stretching are at present the preferred techniques with good long-term functional results. Keywords: Complications, Esophageal Atresia, Morbidity and Mortality, Tracheoesophageal Fistula

Evaluation of a Video Telescopic Operating Microscope (VITOM) for Pediatric Surgery and Urology: A Preliminary Report

Optical magnification is an essential tool in the practice of pediatric surgery. Magnifying loupes are the most frequently used instrument, although their use often comes at the expense of neck pain experienced by the operating surgeon. Recent advances have led to the development of a compact video microscope (VITOM(®); Karl Storz Endoscopy GmbH, Tuttlingen, Germany) that displays high-definition magnified images on a flat screen. This study was designed to evaluate VITOM as a potential substitute for loupes in complex open pediatric procedures and to explore VITOM as an effective intraoperative teaching modality for open surgery. Three surgeons used the VITOM II exoscope in 20 operations: 14 hypospadias repairs, 2 inguinal hernia repairs, 1 sacrococcygeal teratoma resection, 1 recurrent tracheoesophageal fistula repair, and 2 additional procedures. Surgeons, trainees, and surgical technicians subjectively evaluated image quality; surgeons evaluated handling of VITOM, degree of neck strain, and fatigue. Three midlevel surgical trainees assessed the VITOM potential for teaching value. Overall impressions of each group and consensus opinions were generated. All procedures were completed without complication. The consensus opinion of the entire group was that image quality was excellent. The surgeons found VITOM easy to use, and all agreed that neck strain and fatigue were reduced. Surgical trainees felt that VITOM imaging aided in their understanding of procedures and anatomy. Surgical technicians perceived improved operation flow through better visualization of the procedure. VITOM provides excellent visualization of pediatric operations with improved surgeon comfort and may serve as a substitute for loupes. Secondarily, we found enhanced trainee learning and potential improvement in the flow of surgical procedures. Further study of VITOM with a larger sample size and validated tools is needed.

Recurrent Tracheoesophageal Fistula

Repair of recurrent tracheoesophageal fistulas (rTEFs) remains a technically challenging endeavor. Although considered the gold standard, open surgical repair is associated with significant morbidity and rates of recurrence. Over the last 40 years, endoscopic techniques have gained popularity and been touted as a safer first line treatment. This review complies the published articles related to endoscopic repair of rTEFs and reports the various techniques, number of interventions, and success rates. Controversy will remain as to which technique is superior until prospective, multi-institutional studies are performed.

Diagnosis and surgical management of recurrent tracheoesophageal fistulas

Recurrent tracheoesophageal fistula (TEF) is difficult to diagnose and even more difficult to repair. The key to the diagnosis is an adequate contrast study and bronchoscopy. The key to the repair is complete separation of the esophagus from the trachea, with the placement of viable tissue between the two suture lines. I have presented a personal experience with 38 consecutive repairs of recurrent TEFs. The original series of 26 patients had three recurrences, all of which were re-repaired successfully. My more recent experience with the last 12 patients, who were far more complex, was also successful in ultimately repairing the recurrent TEFs.

Combined free autologous auricular cartilage and fascia lata graft repair for a recurrent tracheoesophageal fistula

Repair of recurrent tracheoesophageal fistula (TEF) after repair of congenital esophageal atresia continues to be a difficult problem. The most common re-operation for a recurrent TEF involves repair via a right thoracotomy and use of a flap as interposed tissue between the closure sites. Although several materials have been reported for recurrent fistula repair, natural pedicled flaps have been used in most previous reports. The harvesting of a pedicled flap can sometimes be difficult when the patient has had multiple surgeries. In this report, the successful use of a combined free autologous auricular cartilage and free fascia lata graft repair for a complex patient with multiple recurrent TEFs is described. We believe that our technique should be considered as an approach for patients with recurrent TEF.

Surgical Management Strategy for Intractable Cases of Recurrent Tracheoesophageal Fistula

Surgical Management Strategy for Intractable Cases of Recurrent Tracheoesophageal Fistula

Thoracoscopic Repair of Oesophageal Atresia: Results of a Selective Approach

The repair of oesophageal atresia (OA) and tracheoesophageal fistula (TOF) may be routinely performed via thoracoscopy. However, data on the feasibility and efficacy of thoracoscopic OA/TOF repair are scarce and some authors reported a high rate of anastomotic leak. The aim of this study was to evaluate our concept of OA/TOF repair which includes specific selection of patients and a selective surgical approach. The study was approved by the Institutional Review Board and written informed consent was obtained from all guardians for anonymized data analysis. All patients undergoing OA/TOF repair from June 2001 to December 2011 were included in this analysis. Thoracoscopy was used in cardiorespiratory stable newborns with OA/TOF and a birthweight of ≥ 2000 g. In case of any intraoperative adverse events, lack of progress for ~15 minutes, or anastomosis under tension, the procedure was converted to open thoracotomy. Study endpoints were conversion rate and postoperative complications. A total of 44 newborns with OA/TOF were operated, of whom 22 (6 females, 16 males) met our criteria for a thoracoscopic approach. The mean birthweight of thoracoscopically operated patients was 2760 (2020 to 3960) g, 7 were < 36 weeks of gestation. The mean operative time was 142 (75 to 220) minutes. Thoracoscopy was converted to thoracotomy in eight patients due to problems with exposition (n = 2), ventilation (n = 3), anastomosis under tension (n = 2), or bleeding (n = 1, no transfusion). There was no anastomotic leak in the group of patients who underwent successful thoracoscopic repair, but one recurrence of TOF. Two anastomotic leaks emerged in patients in whom the operation was converted. A total of 7 out of the 22 children required endoscopic dilatation. There was no mortality during a mean follow-up of 5.5 years (43 days to 10.6 years). Our approach included meticulous patient selection and prompt conversion in case of any adverse events. With this approach, thoracoscopic repair of OA/TOF can be safely performed achieving excellent results and a low rate of complications.

Multi-disciplinary hybrid therapy for tracheoesophageal fistula in children: analysis of 4 cases

To explore an innovative technique that is aided by multi-disciplinary hybrid approach in identification and treatment of tracheoesophageal fistula (TEF) in children intraoperatively. From April 2008 to October 2011, 4 patients with isolated TEF were presented with 2 H-type fistulas and 2 recurrent TEF. For all the four cases, with the cooperation of the gastroenterologists, respiratory physician and surgeon, methylene blue was first injected into the trachea for detecting the dye in the esophagus by the gastroscopy. Bronchoscopy was performed where the fistula tract was shown by the methylene blue and a guide wire was passed through the fistula. The patients underwent rigid gastroscopy and the guide wire was identified and brought out through the mouth by biopsy pliers. This created a wire loop through the fistula. X-ray was then used to identify the level of the fistula. According to the level of the fistula it was determined whether surgical incision and approach should be used. The fistula was then repaired successfully by surgery. In the 4 patients, with the aid of gastroscopy and bronchoscopy, identification of the fistula intraoperatively was then facilitated by traction on the loop. The fistula was identified and repaired. There were no fistula recurrences. Multi-disciplinary hybrid therapy for tracheoesophageal fistula in children is beneficial for the precise localization of the fistula. This new technique is an effective and definitive method in identification and treatment of TEF in children.

Recurrent Tracheoesophageal Fistula and Respiratory Failure: The Role of Early Airway Endoscopic Approach

1Department of Emergency, Pediatric Intensive Care Unit, Catholic University of the Sacred Heart, Rome, Italy 2Division of Pediatric Surgery, Department of Pediatrics, “S. Camillo-Forlanini” Hospital, Rome, Italy 3Division of Neonatology, Department of Pediatrics, Catholic University of the Sacred Heart, Rome, Italy 4Division of Neonatology, Department of Pediatrics, “S. Camillo-Forlanini” Hospital, Rome, Italy 5Department of Intensive Care, “A. Meyer” Children Hospital, Florence, Italy

Reporte de caso y revisión de la literatura. Manejo endoscópico de fístula traqueoesofágica recurrente con electrocauterio y pegante tisular

Las fístulas traqueoesofágicas recurrentes (FTER) continúan siendo un reto terapéutico debido a las altas tasas de morbilidad y mortalidad asociadas con su manejo quirúrgico abierto y su recurrencia frecuente. Las técnicas endoscópicas aportan un abordaje alternativo con el potencial de mejorar los resultados y desenlaces quirúrgicos. Se presenta un caso de cierre o reparo endoscópico de FTER mediante el uso de broncoscopia y esofagoscopia, así como una combinación entre técnica con electrocauterio y pegante tisular. Se considera que esta técnica puede representar una alternativa válida para el manejo de esta patología. Igualmente, se señala la importancia de considerar la fístula traqueoesofágica un diagnóstico diferencial en pacientes pediátricos con infecciones respiratorias recurrentes.

Clinical characteristics and treatment of esophageal atresia: a single institutional experience

PurposeTreatment for esophageal atresia has advanced over several decades due to improvements in surgical techniques and neonatal intensive care. Subsequent to increased survival, postoperative morbidity has become an important issue in this disease. The aim of our study was to analyze our experience regarding the treatment of esophageal atresia.MethodsWe reviewed and analyzed the clinical data of patients who underwent surgery for esophageal atresia at Severance Children's Hospital from 1995 to 2010 regarding demographics, surgical procedures, and postoperative outcomes.ResultsSeventy-two patients had surgery for esophageal atresia. The most common gross type was C (81.9%), followed by type A (15.3%). Primary repair was performed in 52 patients. Staged operation was performed in 17 patients. Postoperative esophageal strictures developed in 43.1% of patients. Anastomotic leakages occurred in 23.6% of patients, and recurrence of tracheoesophageal fistula was reported in 8.3% of patients. Esophageal stricture was significantly associated with long-gap (≥3 cm or three vertebral bodies) atresia (P = 0.042). The overall mortality rate was 15.3%. The mortality in patients weighing less than 2.5 kg was higher than in patients weighing at least 2.5 kg (P = 0.001). During the later period of this study, anastomotic leakage and mortality both significantly decreased compared to the earlier study period (P = 0.009 and 0.023, respectively).ConclusionThe survival of patients with esophageal atresia has improved over the years and the rate of anastomotic leakage has been significantly reduced. However, overall morbidities related to surgical treatment of esophageal atresia still exists with high incidence.

Usefulness of dextranomer/hyaluronic acid copolymer in bronchoscopic treatment of recurrent tracheoesophageal fistula in children

Objective Endoscopic repair of recurrent tracheoesophageal fistula (RTF) in infants who underwent surgery at birth for esophageal atresia (EA) is under investigation as an alternative to open surgery, which is technically challenging and associated with high morbidity. The aims of this paper are to present the experience of a single institution in treating RTF using a novel submucosal bronchoscopic injection of biocompatible dextranomer/hyaluronic acid (Dx/HA) copolymer, and to discuss the indications and limitations of this technique. Methods From 2000 to 2007, 6 children (2 boys; 4 girls) aged 1–48 months, weighing 2.5–18 kg were referred to our hospital for respiratory symptoms (pneumonia and failure to thrive) secondary to suspected RTF. All infants had undergone surgery at birth for EA with inferior tracheoesophageal fistula. Bronchoscopy revealed that five infants had RTF and one had a large remnant tracheal upper-pouch fistula. The bronchoscopic intervention was performed under general anesthesia, using a pediatric rigid bronchoscope with a 0° telescope and telemonitoring. The fistula wall mucosa was gently abraded to promote adhesion, and Dx/HA was then injected at two points in the fistula submucosa to obtain a stable swelling of the wall and closure of the RTF. Results In two infants (aged 1 month and 18 months) complete resolution of the RTF was achieved following two separate procedures with a 1-month interval. In three children (aged 2, 18 and 25 months) complete closure of the fistula was not achieved; however, the partial closure was sufficient to address the respiratory symptoms and allow subsequent standard open thoracic surgery without requiring recovery in the intensive care unit. Complete resolution of respiratory symptoms was also obtained following a single endoscopic procedure with two Dx/HA injections in the child with residual pouch fistula. Conclusion Bronchoscopic treatment of RTF with Dx/HA is a simple, minimally invasive, low-risk procedure that enables complete closure of RTF or reduction and resolution of respiratory symptoms, which in turn facilitates uncomplicated thoracic surgery. The technique also provides good results in remnant tracheal upper-pouch fistula.

Recurrent tracheoesophageal fistula after thoracoscopic repair: vanishing clips as a potential sign

We present a case of a neonate who underwent surgery for esophageal atresia (EA) with tracheoesophageal fistula (TEF) with an unusual finding on postoperative chest radiographs. In retrospect, this was a clue to a recurrent TEF: disappearance of the surgical clips from the site of surgical repair. Knowledge of this radiographic finding could aid in the diagnosis of a recurrent fistula in patients with previous repair of EA.

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.

Tracheoesophageal fistula after primary repair of type C esophageal atresia in the neonatal period: recurrent or missed second congenital fistula

Purpose The aim of the study is to investigate whether a tracheoesophageal fistula (TEF) found after the primary repair of type C esophageal atresia (EA) is a recannulation of the original fistula, a missed proximal fistula, or other rare foregut malformation. Methods Between 2000 and 2009, 143 different types of patients with EA were admitted in our hospital. Seven patients (2 from our series, 5 referred to us by other hospitals with the history of primary repair of type C EA) had late presenting TEF. Esophagogram, 3-dimensional computed tomographic (CT) reconstruction, bronchoscopy, and reoperation were performed to confirm the TEF. Their medical records were reviewed and summarized. Results Persistent feeding or respiratory problems were the common symptom. The mean age of the first appearance was 17 ± 26 (1-63) months. Preoperative diagnosis was made by esophagograms and bronchoscopy in 6 patients. Reoperations were performed in all patients through thoracotomy. Missed proximal TEF shown as a distinct fistula above the primary anastomosis without much adhesion was confirmed in 5 cases. A recurrent TEF was found in 1 case. A case of communicating bronchopulmonary foregut malformation was confirmed by 3-dimensional CT reconstruction and reoperation. Conclusion A missed proximal TEF after repair of EA may be misdiagnosed as a recurrent TEF. Accurate preoperative diagnosis depends on combined evaluations of radiologic contrast study, 3-dimensional CT, and bronchoscopy.

Experience in treating congenital esophageal atresiain China

PurposeThe aim of the study was to evaluate our recent experience in treating esophageal atresia (EA) and the outcomes observed at a single center for pediatric surgery. Materials and MethodsThe records of infants with EA from 2006 to 2009 were reviewed. Birth weight, associated anomalies, details of management, complications, and outcomes were examined. ResultsForty-eight consecutive infants with EA were identified from 2006 to 2009, of which 33 (69%) were boys. Mean birth weight was 2668 g (range, 1700-3800 g). Common associated malformations (35%) were cardiac anomalies, imperforate anus, limb anomalies, and chromosomal anomalies. Forty-seven were Gross type C, and one was Gross type A. Forty-five infants underwent ligation of the tracheoesophageal fistula and end-to-side primary anastomosis, and one received a colonic interposition. Six patients died (12.5% mortality). Three died before or during operation because of severe pneumonia and complex cardiac anomalies, and 3 died during recovery (within 1 month after repair) because of aspiration and severe pneumonia (early postoperative mortality was 6.67%). Complications included pneumonia, anastomotic leakage (16%, all recovered after conservative treatment), wound sepsis (11%), recurrent tracheoesophageal fistula (9%) (3/4 recovered after conservative treatment), anastomotic stricture (10%), and gastroesophageal reflux in about 2 of 3 patients. Preoperative computed tomographic imaging and 3-dimensional graphic reconstruction used in 15 patients were useful. ConclusionsMost patients with EA have excellent short- to midterm surgical outcomes. The main factors for mortality are complex cardiac anomalies, aspiration, and pneumonia. Computed tomographic imaging and 3-dimensional graphic reconstruction can provide surgeons with excellent preoperative reference about the anatomy of the defect. Most anastomotic related complications resolve with conservative treatment. Patients of low-risk prognosis group with type A and long gap EA can be managed with a primary colonic interposition with good results. The main midterm complications are gastroesophageal reflux and stricture.