Recurrent Tracheo-oesophageal Fistula Research Articles

Anaesthetic considerations for slide tracheoplasty for the management of recurrent tracheo-oesophageal fistula.

Anaesthetic considerations for slide tracheoplasty for the management of recurrent tracheo-oesophageal fistula.

Repair of oesophageal atresia by consultants and supervised trainees results in similar outcomes.

Consultants and trainees require exposure to complex cases for maintaining and gaining operative experience. Oesophageal atresia (OA) repair is a neonatal surgical procedure with indicative numbers for completion of training. A conflict of interest may exist between adequate training, maintaining consultant experience and achieving good outcomes. We aimed to review outcomes of procedures performed primarily by trainees and those performed by consultants. We carried out a retrospective case note review of all consecutive infants who underwent surgical repair of OA with distal tracheooesophageal fistula (TOF) between January 1994 and December 2014 at our institution. Only cases that underwent primary oesophageal anastomosis were included. Surgical outcomes were compared between cases that had a trainee and those that had a consultant listed as the primary operator. One hundred and twenty-two cases were included. A total of 52 procedures were performed by trainees, and 68 by consultants. Two cases were undeterminable and excluded. Infant demographics, clinical characteristics and duration of follow-up were similar between groups. All infants survived to discharge. Procedures performed by trainees and those performed by consultants as primary operators had a similar incidence of postoperative pneumothorax (trainees 4, consultants 3; p=0.46), anastomotic leak (trainees 5, consultants 3; p=0.29) and recurrent TOF (trainees 0, consultants 2; p=0.5). Overall 52% of cases had an anastomotic dilatation during follow-up, with no difference between the trainee and consultant groups (50% vs 53%; p=0.85). Surgical outcomes for repair of OA/TOF are not adversely affected by trainee operating. Trainees with appropriate skills should perform supervised OA/TOF repair. These data are important for understanding the interrelationship between provision of training and surgical outcomes.

Recurrent tracheo‐oesophageal fistula due to foreign body ingestion in an adult

Foreign body ingestion can result in various oesophageal complications. Tracheoesophageal fistula (TEF) as a complication is rare as it is usually caused by cuffed endotracheal tubes, burn injuries, trauma, infection, and malignancy. Recurrent trachea-oesophageal fistulas are even more uncommon. We are presenting here a case of a 25 year old male who presented with a recurrent tracheo-oesophageal fistula. An innovative technique of repair was used with a successful outcome.

The treatment of recurrent tracheo-oesophageal fistula with biosynthetic mesh

1,2 the incidence of which is reported as 5 - 15%. Secondary recurrences following fistula re-closure are also not uncommon. 3 Traditional therapy for a recurrent tracheo-oesophageal fistula (RTF) involves a repeat thoracotomy, with its associated risks and significant morbidity. An endoscopic procedure provides an attractive alternative. Use of a bronchoscopic technique was first reported in 1975 by Gdanietz and Krause, 4 who used histo-acryl adhesive to close an RTF. Since then, a variety of other endoscopic techniques have been reported. The strategies employed in these techniques include plugging the fistula with fibrin glue or tissue adhesives, 3 plugging it after de-epithelisation of the fistula, 5,6 or obliteration of the fistula using cauterisation or laser therapy. 7 More than one treatment session was needed in most of the cases reported in which these techniques were used. Recently Keckler et al. 8 reported successful obliteration of an RTF with two successive applications of Surgisis biological mesh (Cooke Inc., Bloomington, Ind.). Encouraged by their results, we used Permacol (TissueScience, Hampshire, UK), a porcine dermal biological mesh, on a 6-month-old baby with an RTF. Only a single application of Permacol was necessary. In this patient, rigid bronchoscopy revealed a recurrent fistula a few millimetres proximal to the carina. To create a raw surface, de-epithelisation of the fistula tract was performed with an endoscopic brush. Using an endoscopic grasper, a 3 mm × 3 mm piece of Permacol was introduced and pushed into the fistula until it was seen through a gastroscope to be close to the opening in the oesophagus. Four more similar pieces of Permacol were introduced. DuraSeal (Confluent Surgical Inc., Waltham, Mass.) was then injected into the fistula tract with an extended tip applicator. The DuraSeal was used to seal off the Permacol and keep it in position. The patient was extubated and kept on nasogastric feeds for 48 hours, after which oral feeds were started. Postoperative recovery was uneventful. A postoperative oesophagram on day 4 was normal. The patient continued to recover and remained asymptomatic 24 months after this procedure. Permacol provides a long-lasting and stable collagen lattice that allows the incorporation of fibroblasts and capillaries to form a growing scar. Experimental evidence suggests that the biosynthetic scaffold degrades over time, but that the tissue remodelling that replaces it is stronger than the native tissue. The use of biosynthetic mesh has gained wide acceptance. It has been used with encouraging results in the repair of diaphragmatic hernias, abdominal and thoracic wall defects and para-oesophageal hernias. 9-11 The bronchoscopic placement of biosynthetic mesh is an added modality in the treatment of the difficult problem of RTF, and holds great promise. This bronchoscopic procedure is easy to perform and is repeatable if necessary. It is a much less invasive and less risky procedure than the alternative, repeat thoracotomy, and should be considered as a good treatment option for patients with an RTF.

Success and failure with neonatal tracheo-oesophageal anomalies

In seven and a half years, one surgical team treated 67 consecutive neonates with oesophageal atresia and/or tracheo-oesophageal fistula. According to Waterston's classification, 28 were in group A, 12 in group B and 27 in group C. The mortality rate during the initial admission was 10 per cent, all seven deaths being unavoidable in infants in group C with multiple anomalies. Birthweight alone had no bearing upon the chances of survival. Primary oesophageal repair, including one suture-fistula procedure and one delayed primary repair, was attempted in 54 (84 per cent) of the 64 patients with atresia and was successful in 46 (85 per cent). All three H-type tracheo-oesophageal fistulae were successfully divided in infants in group A. Recurrent tracheo-oesophageal fistula developed in four (7 per cent) infants, one of whom (group A) underwent successful repair. One disrupted anastomosis was successfully resutured (group A), so an intact oesophagus was finally achieved in 51 patients, of whom six (12 per cent) developed anastomotic strictures and 21 (41 per cent) underwent surgery for gastro-oesophageal reflux. Of the 60 early survivors, 10 (17 per cent) underwent aortopexy for tracheomalacia. Whenever possible, primary repair is advocated in all infants. Even for those in group C with multiple, severe associated anomalies, the combined early and late mortality was no greater following primary repair (7 died of 12 operated) than after staged repair (4 died of 7 operated), but major anastomotic complications were more common in infants in group C (5 out of 19) than in those in groups A and B (3 out of 38).

The management of combined oesophageal and duodenal atresia.

Duodenal atresia (DA) in babies with oesophageal atresia (OA) is associated with significant morbidity and mortality. The management protocol for this combination of anomalies is not well defined and evolving. The aim of this study was to review our experience with combined OA and DA and to note the evolving trend in management at Sydney Children's Hospital. Over the last 30 years, 225 babies with OA have been treated at our institution. Ten babies had associated DA. A total of 19 anomalies were noted; one child had multiple lethal anomalies and received no treatment. In three babies the diagnosis of associated DA was missed initially. For the nine babies who were treated, four had a primary OA repair followed by a delayed DA repair; one had cervical oesophagostomy, gastrostomy and DA repair; and two had a simultaneous repair of OA and DA with a gastrostomy. The last two patients in this series have had a primary simultaneous repair of both anomalies without a gastrostomy. The complications noted in the nine patients treated included anastomotic strictures in five, recurrent tracheo-oesophageal fistula in one, food bolus obstruction in one, and a megaduodenum requiring tapering in one. We believe that adopting a management protocol of primary simultaneous repair of both anomalies without a gastrostomy is justified. There was no apparent increase in morbidity and mortality with such an approach.

Treatment of recurrent tracheo-oesophageal fistula in an infant using bronchoscopic I application of fibrin glue

SummaryRecurrent tracheo-oesophageal fistula (TEF) is the most common and serious complication of the treatment of oesophageal atresia with TEF. Following this complication, the patient might need several operations. In this study, the authors report on the treatment of recurrent TEF using bronchoscopic application of fibrin glue (FG) to the fistula tract.

Endoscopic treatment of recurrent tracheo-oesophageal fistulae: long-term results.

Recurrent tracheo-oesophageal fistula (RTOF) occurs in 5%-15% of patients following oesophageal atresia repair. Re-thoracotomy is technically challenging and associated with significant morbidity, including a re-fistulation rate of 10%-22%. Endoscopic occlusion of the RTOF with tissue adhesives (fibrin glue, Histoacryl) is reported to be safe and highly effective. However, long-term results of such therapy are absent from the literature. A postal survey of 13 institutions reporting the use of such treatment regimes for RTOF in the literature between 1974 and 1995 was performed, and data collected concerning the long-term outcomes of their reported patients. Eleven institutions responded to the request for data, providing 22 patients (age range 1 month to 12 years) for review. All had undergone initially successful RTOF closure by endoscopic methods and had been followed up for a median of 107 months (range 3-264 months). There was no morbidity or mortality directly related to the procedure. Overall, only 55% of these endoscopically treated fistulas remained closed long-term. Fistula recurrence invariably occurred within 12 months of successful therapy (median 46 days, range 9-335). Most patients required multiple endoscopic procedures to achieve successful RTOF closure (median 2.0, range 1-4 attempts), although significantly fewer attempts were required with fibrin glue therapy. Surgical re-exploration remains the treatment of choice in the fit child. Endoscopic therapy offers a safe and elegant alternative to high-risk surgery in the sick child, although repeated treatments may be required for successful RTOF closure.

Roentgenologic demonstration of recurrent tracheooesophageal fistula following surgical repair of congenital oesophageal atresia.

Roentgenologic demonstration of recurrent tracheooesophageal fistula following surgical repair of congenital oesophageal atresia.

Roentgenologic Demonstration of Recurrent Tracheo-Oesophageal Fistula following Surgical Repair of Congenital Oesophageal Atresia

Roentgenologic Demonstration of Recurrent Tracheo-Oesophageal Fistula following Surgical Repair of Congenital Oesophageal Atresia