Recurrent Tracheoesophageal Fistula Research Articles

Post-esophageal atresia repair double acquired tracheoesophageal fistulas treated successfully by gastric transposition: a case report

BackgroundPostoperative recurrence of tracheoesophageal fistula (TEF) is a frequent complication in the repair of esophageal atresia (EA). Based on the recent etiologic classification, a TEF that develops in a different new pathway from the original one is categorized as an acquired TEF. The TEFs that fall into this category have been reported to be refractory and their mechanisms have not been fully understood. Here, we report the complicated case of an acquired TEF derived from mediastinitis after the original TEF repair developed an anastomotic stricture. The TEF contained double fistulas, both towards the right lobe bronchi, and was repaired by gastric transposition through a retrosternal route.Case presentationThe patient was diagnosed with Gross C esophageal atresia after birth and underwent tracheoesophageal fistula banding during the neonatal period. He experienced an intractable anastomotic stenosis after surgery which was treated with repeated balloon dilation therapy. By the age of 11 months, he developed a mediastinal abscess that improved with conservative treatment. At 18 months old, a fistula from the esophagus to the right superior lobe bronchus was identified. The patient underwent a right upper lobectomy to resect the fistula. However, at 21 months old, another fistula to the right lower lobe was revealed. An esophageal banding was done to relieve the respiratory symptoms. This was followed by esophagectomy and gastric transposition through the retrosternal route at 26 months old. The patient started rehabilitation and oral intake gradually after surgery. By 3 years after gastric transposition, he could already take blended food orally with the support of small amounts of enteral feeding.ConclusionCases of TEF derived from severe inflammation have the potential to form a complicated network and lead to recurrence. Surgeons should consider the possibility of multiple tiny fistulas in cases of severe acquired TEF. These may be repaired successfully by gastric transposition through the retrosternal route.

Recurrent tracheoesophageal fistula secondary to clips migration after thoracoscopic esophageal atresia repair

Recurrent tracheoesophageal fistula secondary to clips migration after thoracoscopic esophageal atresia repair

Low gestational age is associated with less anastomotic complications after open primary repair of esophageal atresia with tracheoesophageal fistula

BackgroundThe aim of this study was to evaluate anastomotic complications after primary one-staged esophageal atresia (EA) repair relating to the patients` gestational age (GA).MethodsRetrospective data analyses of patients who underwent closure of tracheoesophageal fistula (TEF) and primary esophageal anastomosis from 01/2007 to 12/2018 in two pediatric surgical centers. Exclusion of EA other than Gross type C, long-gap EA, minimal invasive or staged approach. Postoperative complications during the first year of life were assessed. Associated malformations, the incidence of infant respiratory distress syndrome (IRDS) and intraventricular bleeding were analyzed.ResultsInclusion of 75 patients who underwent primary EA repair. Low GA was associated with significantly lower incidence of anastomotic complications (p = 0.019, r = 0.596, 95% CI 0.10–0.85). Incidence of anastomotic leakage (0% vs. 5.5%; p = 0.0416), recurrent TEF (0% vs. 5.5%; p = 0.0416) und anastomotic stricture (0% vs. 14.5%; p = 0.0019) was significantly lower in patients < 34 gestational weeks. Incidence of IRDS (55% vs. 0%; p < 0.0001) and intraventricular bleeding (25% vs. 3.6%; p = 0.0299) was significantly higher in patients < 34 gestational weeks.ConclusionsDespite prematurity-related morbidity, low GA did not adversely affect surgical outcome after primary EA repair. Low GA was even associated with a better anastomotic outcome indicating feasibility and safety of primary esophageal reconstruction.

Comparison of Detection Methods for Tracheoesophageal Fistulae With a Novel Method: Capnography With CO2 Insufflation.

Tracheoesophageal fistulae (TEF) are difficult to detect and require a high index of suspicion. We hypothesized that capnography to identify a spike in end-tidal carbon dioxide (etCO2) during esophagoscopy with carbon dioxide (CO2) insufflation would facilitate TEF diagnosis because of gas passage from the esophagus to the trachea. Medical records of 42 consecutive cases of recurrent, acquired, or missed congenital TEF diagnosed between January 2015 and November 2019 that underwent esophagoscopy with CO2 insufflation were reviewed. A control cohort of 97 similarly endoscopically evaluated patients with surgical confirmation of absence of recurrent TEF (eg, patients undergoing posterior tracheopexy) was also collected. All patients underwent pre-operative esophagoscopy, bronchoscopy, and capnography; diagnostic abilities of various combinations of modalities for TEF identification were calculated. Statistical analysis identified a maximum intra-esophagoscopy end-tidal CO2 level of 68 mmHg as the optimal discriminator between cases and controls, though in practice, we anecdotally find that recurrent TEFs typically permit rapid rise ≥90 mmHg. Increasing numbers of diagnostic modalities increased diagnostic sensitivity to detect recurrent TEF; the highest diagnostic sensitivity for TEF identification was achieved by the combination of intra-esophagoscopy fluoroscopy with bronchoscopy and capnography ≥68 mmHg (sensitivity = 88.1%). There were multiple cases of TEF (N = 7 for etCO2 ≥68 mmHg, N = 3 for etCO2 ≥90 mmHg) identified by capnography that were missed by esophagoscopy. There were 5 (for etCO2 ≥68 mmHg) or 6 (for etCO2 ≥90 mmHg) cases of recurrent TEF that were missed by all nonsurgical methods. Attention to etCO2 during esophagoscopy with CO2 insufflation represents a simple, novel way to detect TEF. Identification of TEF remains challenging, though combinations of diagnostic modalities improve diagnostic sensitivity.

Thoracoscopic surgery for recurrent tracheoesophageal fistula after esophageal atresia repair.

We aimed to investigate the safety, feasibility, and outcomes of thoracoscopic surgery for recurrent tracheoesophageal fistula (rTEF) after esophageal atresia repair. The medical records and follow-up data of 31 patients who underwent thoracoscopic surgery for rTEF at a single institution were collected and reviewed. In total, 31 patients were enrolled with a median age of 7months (range: 3-30months) and a median weight of 6,000g (range: 4,000-12,000g) before reoperation. The median operation time for the entire series was 2.9hours (range: 1.5-7.5hours), and the median total hospitalization duration after surgery was 19days (range: 11-104days). One patient died of anastomotic leakage, a second rTEF, severe malnutrition, and thoracic infection; the mortality rate was 3.23% (1/31). Nine patients (9/31, 29.03%) had an uneventful recovery, and the incidences of postoperative anastomotic leakage, anastomotic stricture, and second rTEF were 25.81%, 61.29%, and 9.68%, respectively. After a median follow-up of 12months (range: 3-24months), 26 survivors resumed full oral feeding, 2 were tube fed, 2 required a combination of methods, and 4 patients experienced severe respiratory complications. In total, 9 patients had pathological gastroesophageal reflux, and 2 patients eventually underwent Nissen fundoplication. Of the 30 survivors with growth chart data, the median weight for age Z-score, height for age Z-score, and weight for height Z-score were-0.46 (range: -5.1 to 2.8), 0.75 (range: -2.7 to 4.7), and-1.14 (range: -6.8 to 3.0), respectively. Thoracoscopic surgical repair for rTEF is safe, feasible, and effective with acceptable mortality and morbidity.

Use of free thymic fat pad for recurrent tracheoesophageal fistula operation following esophageal atresia repair

Abstract A 2-month-old boy who had undergone radical surgery for esophageal atresia at 10 h after birth started to present intermittent choking and coughing during suckling and sleep. Upper gastrointestinal series revealed recurrent tracheoesophageal fistula at the Th3 level. Enteral feeding via trans-jejunal tube was started and reoperation was performed at 10 months old, when he weighed 9.6 kg (+0.56SD). Thoracotomy was performed after inserting the guidewire into the fistula under both bronchoscopy and gastroscopy. The fistula was resected and both esophageal and tracheal ends were sutured. Part of the thymus was obtained and the free thymic fat pad (FTFP) was interposed between sutured sites along with the application of fibrin-glue to the affected area to prevent re-recurrence. Postoperative course was uneventful and computed tomography (CT) at 1 month following the operation demonstrated the residual FTFP. FTFP can be a feasible, useful, and effective option for interposition in recurrent TEF surgery, compared to conventional pedicled or free tissue.

Özofagus Atrezisi ve/veya Trakeoözofageal Fistül Cerrahisi Sonrası Solunum Sistemi Erken ve Geç Dönem Komplikasyonlarının İncelenmesi

INTRODUCTION: Esophageal atresia (EA) and/or tracheoesophageal fistula (TEF) is one of the common developmental anomalies of the foregut. Despite advances in surgical techniques and postoperative care, respiratory system complications affect the quality of life of patients. We planned to evaluate our patients in terms of the general features, the risk factors for respiratory morbidity and short- and long-term respiratory complications after surgical treatment. METHODS: Thirty-six patients with EA and/or TEF and followed after surgical treatment between 2002 and 2019 were retrospectively enrolled in the study. RESULTS: The most common symptom was chronic cough (77.7%) and wheezing (41.6%). Recurrent pulmonary infections were present in the majority. The number of pulmonary infections was high in patients who had dilatation due to stricture(N=14) and in patients with recurrent TEF(N=6) and malacia(N=10). Bronchiectasis was present in 8 patients and hospital admission due to infections was high. Aeroallergen sensitivity was detected in four patients and food allergy in five patients. Scoliosis was present in 33.3% of the patients all of whom had recurrent pulmonary infections. Pulmonary function tests were performed in 10 patients. Five patients had impaired pulmonary function. Medical treatment for reflux was given to the majority of patients (N=30), while fundoplication was performed in 10 patients. Most of the patients had a significant decrease in the frequency of pulmonary infections after the procedure. DISCUSSION AND CONCLUSION: The etiology of pulmonary complications is multifactorial and many factors affect each other. Evaluation and management of the patients for each complication will improve the quality of life and comfort of the patients.

Benign Tracheal Esophageal Fistula

Benign acquired tracheoesophageal fistula (TEF) is a rare complication related to prolonged mechanical ventilation, esophageal and mediastinal surgeries, chest trauma, or infection. TEF should be suspected in ventilated patients with persistent air leak, recurrent pneumonias, or those with persistent cough immediately following swallowing (Ono sign). Once identified, the only definitive solution for TEF is surgical correction. In preparation for surgical repair, most opt to wean patients from the ventilator and place a percutaneous gastrostomy tube for diversion. Surgical management of TEF varies based on size, location, and etiology. This article describes step-by-step repair of cervical and cervicothoracic TEFs via low anterior cervical collar approach. This technique offers greater exposure and has lower risk of devascularization and recurrent laryngeal nerve injury. Success rates approach 95%, with postintubation injury and TEF recurrence being the most common complications.

Acquired Tracheoesophageal Fistula After Esophageal Atresia Repair

Background:Recurrence of tracheoesophageal fistula is a frequent complication after esophageal atresia repair. Acquired tracheoesophageal fistulas are long new fistulas that are localized at sites that are not typical of the congenital tracheoesophageal fistula. We present four cases to discuss the diagnostic and management challenges concerning various acquired tracheoesophageal fistula localizations.Case Report:We retrospectively evaluated the medical records of patients admitted with acquired tracheoesophageal fistula in the last 5 years. Among the 16 postoperative tracheoesophageal fistulas, 4 were classified as acquired tracheoesophageal fistula. Patients’ admission age ranged from 1 to 8 years. The female to male ratio was 2:2. The presented cases were admitted with recurrent respiratory tract infections, choking, and coughing. The acquired tracheoesophageal fistulas were observed between the esophagus and cervical trachea, between the esophagus and the right bronchus passing through intrathoracic abscess cavity, in the right bronchus, and between the colon conduit and trachea. One of the acquired tracheoesophageal fistulas healed spontaneously, whereas others required surgical ligation.Conclusion:Acquired tracheoesophageal fistula most often occurs secondary to local or diffuse mediastinitis. Acquired tracheoesophageal fistula may appear at unusual sites not typical of congenital tracheoesophageal fistula, such as esophagus-to-right bronchus and conduit to trachea. Therefore, the unusual locations of acquired tracheoesophageal fistula should be borne in mind, and patients evaluated and managed more comprehensively.

The repair of esophageal atresia and major complications—a systematic review and our experience in dealing with the tracheoesophageal fistula

Esophageal atresia (EA) is a rare and complicated congenital malformation. Since it was first reported, it has had a long history. Nowadays, standard treatment options consist of open procedure and thoracoscopic surgery. Each procedure has its benefits and defects, and the relative merits of both methods are still debated. We conducted a systematic literature review on the surgical repair of the EA, from the first descriptions of EA with tracheoesophageal fistula (TOF) appeared in the 19th century to 2018. The opening and the laparoscopic surgery are the two effective methods to deal with the EA, and they all have their benefits and some aspect to be improved. The main complications for the operation were anastomotic leakage, anastomotic stenosis and recurrence of TOF. Results indicate that the patients of opening surgery were more likely to have leakage, but these patients also showed a lower stenosis rate than the thoracoscopy patients. Meanwhile, the rate of recurrence for TOF had no statistical difference between the procedure types. Thoracoscopic surgery was beneficial and promoted a good prognosis in EA patients when compared to open surgery, although there is still more research to be done in this regard.

DOZ047.110: Recurrent tracheoesophageal fistula tracheoscopic chemocauterization with trichloroacetic acid

Abstract Objective The aim of this study was to report the experience of two centers in the treatment of recurrent tracheoesophageal fistula (RTEF), by tracheoscopic chemocauterization with trichloroacetic acid (TCA). A surgical approach to RTEF has high morbidity and mortality. Some endoscopic techniques have been developed but nevertheless, optimal treatment is still not determined because of the low number of patients, short term of follow-up, and different techniques. Materials and Methods From January 2016 to March 2019, 12 patients with RTEF were selected for endoscopic management in two centers. Eleven had RTEF after primary repair of esophageal atresia/TEF and one had a second fistula with misdiagnosis, all of them by a thoracotomy approach. In all cases the diagnosis was confirmed by clinical evaluation, esophagram, and bronchoscopy. Under general anesthesia, a rigid pediatric bronchoscope with a 0° rod lens telescope telemonitoring was used to localize and refresh the fistula with a small endoscopy brush of 2–3 mm. Cotton soaked with 50% TCA was applied on the fistula for 30 seconds. The procedure had to be repeated two times. Results Fistulae were closed in 10 patients. The closure was confirmed by esophagram or bronchoscopy after 2 months of the procedure. It remains completely obliterated and the patients are asymptomatic. There were only two patients with progressive decrease in the diameter of the fistula; one patient died for some other medical reason and another patient is being treated. The mean number of procedures in each patient was 1.3, and the follow-up was 12 months on average (2–36). Two patients had bronchospasms as postoperative complication. Conclusion The tracheoscopic chemocauterization of RTEF with the use of 50% TCA is a minimally invasive, safe, and effective technique. It has fewer complications and avoids the morbidity of open surgery.

DOZ047.22: FEED-EASY: feeding disorders in children with esophageal atresia study

Abstract Introduction With advances in surgical and neonatal care, survival of patients with esophageal atresia (EA) has improved over time. While a number of conditions associated with EA may have an impact on feeding development (delayed primary anastomosis, anastomotic leaks, recurrent tracheoesophageal fistula, anastomotic stricture, gastroesophageal reflux, esophageal dysmotility, etc.) and although children with EA experience a number of oral aversive events in their first year of life, feeding disorders (FD) are poorly described and frequently unrecognized. The primary aim of this study was to describe FD in children born with EA, with a standardized scale. The secondary aim was to describe conditions associated with FD. Methods FEED-EASY is a multicentric French study. Parents of children born with EA between 2013 and 2016 in one of the 22 participating centers were asked to participate and received the French version of the standardized and reproductive ‘Montreal Children's Hospital Feeding Scale (MCH-FS)’. Results One hundred and forty-five children were included; 61 (42%) had FD according to the MCH-FS. These children were characterized by disinterest in food, oral hypersensitivity, difficulty in touching some textures and food avoidance, with an influence in quality of life. Nineteen (13%) were tube-fed between 1 and 4 years of age. Birth weight and chronic respiratory difficulties were associated with FD in children with EA. Anastomotic stricture (present in 31% of the included children) was not associated with FD. Conclusions FD is frequent and unrecognized in children with EA, and can influence growth and quality of life. MCH-FS allows pediatricians to identify FD in children with EA within a couple of minutes.

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.

DOZ047.78: Endoscopic management of symptomatic tracheal pouches with trichloroacetic acid chemocauterization

Abstract Introduction Trichloroacetic acid (TCA) has been used in different conditions such as recurrent and congenital tracheoesophageal fistula and branchial sinus of the pyriform fossa. Nevertheless, it has never been described as a treatment for symptomatic tracheal pouches after an esophageal atresia repair. This study reports two cases of endoscopic treatment with TCA of symptomatic residual tracheal pouches in 2 children with repaired type III esophageal atresia. Case Reports Two cases of 7 and 8 years with esophageal atresia type III repaired in the neonatal period. Both were diagnosed with severe tracheomalacia and presented recurrent pulmonary infections complicated with pulmonary bronchiectasis. One of the patients benefited from a Nissen fundoplication due to severe gastroesophageal reflux at 2 years of life. Due to persistent respiratory infections bronchoscopy was indicated detecting a blind 2 cm tracheal pouch at the level of the carina in both patients. Endoscopic treatment by the use of TCA was performed. By rigid bronchoscopy chemo-cauterization of the pouch with 50% TCA followed by a brush abrasion of the mucosa was done. Postoperatively one of the patients developed a slight and limited subcutaneous and mediastinal emphysema due to postoperative cough. No other complications were reported. Endoscopic control at 3 months (and also 12 in 1 case) after procedure showed complete obliteration of the tracheal pouches. After a medium follow-up of 17.5 months (14 and 21) a significant decrease in the number of respiratory infections and hospital admissions has been observed in both cases. Conclusion Endoscopic treatment by the use of 50% TCA in symptomatic tracheal pouches seems safe and effective. The complex surgical corrections of these conditions make it a perfect indication, representing a minimally invasive alternative.

DOZ047.91: Bronchoscopic treatment of recurrent tracheoesophageal fistula: is it an effective option?

Abstract Purpose Despite technical and surgical improvements, treatment of recurrent tracheoesophageal fistula (rTEF) still remains a challenging problem in pediatric patients. Bronchoscopic closure of rTEF using different agents is described with different success rates in the literature. This study aimed to report results of patients with rTEF treated with chemocauterization using trichloroacetic acid (TCA) and with laser cauterization (LC) followed by fibrin glue (FG) application. Methods Nine patients with rTEF were included in the study from 2014 to 2018. Four patients underwent fistula closure with LC followed by FG application, while another four patients had chemocauterization with TCA. In one case both agents were used. Patients were checked for the success of the treatment by bronchoscopy. All patients had the diagnosis of rTEF. Seven patients had EA with distal TEF and the remaining two patients had H-type TEF as primary pathologies. FG application was performed by LC followed by injection of FG into the fistula. Application of the TCA was made by a TCA-soaked sponge for 30 seconds and 3 times each trial. Results Nine children of the age range 4 months to 5 years (mean 1.5 year) were treated endoscopically. Follow-up ranged between 3 months and 5 years (mean 28 months). Among the nine patients only in one patient with only laser coagulation with FG application the treatment was successful. In the remaining eight patients all attempts failed. All these patients underwent open surgical closure of the fistula. There were no acute or late complications related to either endoscopic method. Conclusion The results of this study suggest that endoscopic occlusion of recurrent TEF has a low success rate. Surgical closure is still a standard method with a high success rate. Even though endoscopic options are less invasive, they prolong the period of aspiration and may cause increased pulmonary problems.

The Use of Endoclips in Thoracoscopic Correction of Esophageal Atresia: Advantages or Complications?

Background: Thoracoscopic correction of esophageal atresia (EA) with tracheoesophageal fistula (TEF) has been increasingly widespread, but is still one of the most advanced pediatric surgical skills. This procedure has a challenging learning curve, and usually initially requires a longer operative time than the open approach; furthermore to perform this intervention, the surgeon must be very experienced in endocorporeal knotting. In our opinion, standardization of the technique and the application of "tricks" (including the use of titanium endoclips for TEF closure) to make surgical steps easier, faster, and safe would be useful to the surgeon and to the patient above all. Materials and Methods: We present our experience in thoracoscopic treatment of EA/TEF over the past 12 years; during this period, we have treated 32 neonates. We reviewed all patient clinical records evaluating demographics, surgical technique, postoperative period, and long-term follow-up. Results: Thirty-one patients were affected by type C EA (five presented with a long-gap defect); one by type E EA. Mean gestational age was 36 + 5 weeks (29-41). Mean weight at surgery was 2340 g (990-3715 g). Through a transpleural thoracoscopic approach, after Azygos vein division, TEF was closed by sutures (silk/polydioxanone [PDS]) in 4 patients while in the remaining 28 two 5 mm titanium endoclips were applied. Esophageal anastomosis was then performed with 8-12 interrupted 5/0 absorbable sutures. We had two intraoperative complications in endoclips application (migration and misplacement), which were immediately resolved. After a contrast study on sixth to seventh postoperative day (average eighth), in the absence of leakage, oral feeding was started and chest tube removed. Four to six weeks after surgery, patients underwent endoscopic evaluation. At a follow-up of 9 years, we had no postoperative complications due to endoclips: neither TEF recurrence, nor problems due to clips dislocation. Conclusions: Although the benefits of thoracoscopic correction of EA/TEF are still discussed, we agree with this part of recent literature that considers thoracoscopic approach as a feasible, safe, and advantageous alternative to the traditional open approach. We also want to emphasize that in our experience, TEF closure by titanium endoclips is fast, reducing operative time, and effective, with no reported long-term complications in our case series. Overall success rate after clips application is, in our series, 100%. The only limit we have found, above all for low-weight patients, is the diameter of the clip applier which needs a 5 mm access even if the surgeon uses 3 mm operative instruments.

A new esophageal elongation technique for long-gap esophageal atresia: in vitro comparison of myotomy techniques

Complications such as stricture, leakage, recurrent tracheoesophageal fistula and mucosal pouch are commonly seen in myotomy techniques used for long-gap esophageal atresia (LGEA) treatments. Therefore, we think that there is a clear need for other techniques which would enable us to create more robust and longer esophagus in such cases. In this study, we reviewed multiple V-myotomy (VM) technique and the differences of the said technique with Livaditis circular myotomy (LM) and Kimura spiral myotomy (KM) techniques using literature as an aid. 21 esophagus samples from 21 male lambs aged 12months were used in vitro for the study. All esophageal samples were matched to have a length of 120mm. Samples were divided into 3 groups of 7 and VM, LM and KM techniques were used in each group, respectively. Post-op esophagus lengths, elongation amount with each incision and perforation pressures were measured. Post-op esophageal lengths were measured as 227, 210 and 200mm for VM, LM and KM, respectively. Elongation amount per incision was measured as 5.1, 4 and 3.34mm, again in previous order of VM, LM, and KM. Finally, perforation pressure following VM, LM, and KM was measured as 460, 400, and 410mmHg. VM was found to significantly increase total esophagus length and elongation per incision over LM and KM. In addition, VM was also shown to have a higher perforation pressure. Although in vivo live animal studies are required, we can say that VM can be used to create longer and robust esophagus.

Cautery ablation of a remote recurrent tracheoesophageal fistula

Abstract Complications subsequent to repair of a congenital tracheoesophageal fistula (TEF) with esophageal atresia (EA) include leak at the anastomosis, stricture formation, and recurrent fistula. Recurrence is uncommon, and the optimal management for a recurrent fistula is debatable. As many of the symptoms of TEF recurrence are similar to common postoperative sequelae, diagnosis of these recurrences can be quite challenging. We report the case of a 12 year old patient with a history of Type B EA/TEF (proximal pouch fistula, distal atresia) who was discovered to have a TEF recurrence over a decade after his initial repair which was successfully treated with cautery ablation of the fistula tract.

Recurrent tracheoesophageal fistula in an adolescent without persistent symptoms

Rationale:Congenital esophageal atresia (EA) and tracheoesophageal fistula (TEF) ininfants have been treated well with surgery. Approximately 10% of children displayed recurrent fistula. In the present case, we reported recurrent TEF in an adolescent as a complication of EA/TEF in infancy.Patient concerns:An infant was diagnosed with gross type C congenital EA and TEF and subsequentlyunderwent repair in early infancy, with division of the TEF and primary esophageal anastomosis. Postoperative esophageal strictures developed and were relieved by bougienage of the esophagus partially. Then, the child had normal growth with mild symptoms, mainly choking when drinking water. At 11 years of age, the child developed fever and cough, and massive bronchiectasis in lobus inferior pulmonis sinister was found.Diagnosis:Recurrent tracheoesophageal fistula.Interventions:Division of the TEF and esophageal replacement with gastric tube was performed as treatmentOutcomes:The child recovered well.Lessons:Recurrent tracheoesophageal fistula aftercongenital EA and TEF could be diagnosed in adolescence. Massive bronchiectasis might develop without apparent symptoms.

Respiratory problems in children with esophageal atresia and tracheoesophageal fistula

BackgroundChildren with congenital esophageal atresia (EA) and tracheoesophageal fistula (TEF) have chronic respiratory symptoms including recurrent pneumonia, wheezing and persistent cough. The aim of this study is to describe the clinical findings of a large group of children with EA and TEF surgically corrected and the instrumental investigation to which they have undergone in order to better understand the patient’s needs and harmonize the care.MethodsA retrospective data collection was performed on 105 children with EA and TEF followed at Department of Pediatric Medicine of Bambino Gesù Children’s Hospital (Rome, Italy) between 2010 and 2015.Results69/105 (66%) children reported lower respiratory symptoms with a mean age onset of 2.2 ± 2.5 years and only 63/69 (91%) performed specialist assessment at Respiratory Unit. Recurrent pneumonia (33%) and wheezing (31%) were the most reported symptoms. The first respiratory evaluation was performed after surgically correction of gastroesophageal reflux (GER) at mean age of 3.9 ± 4.2 years. Twenty nine patients have undergone to chest CT with contrast enhancement detecting localized atelectasis (41%), residual tracheal diverticulum (34%), bronchiectasis (31%), tracheal vascular compression (21%), tracheomalacia (17%) and esophageal diverticulum (14%). Fifty three patients have undergone to airways endoscopy detecting tracheomalacia (66%), residual tracheal diverticulum (26%), recurrent tracheoesophageal fistula (19%) and vocal cord paralysis (11%).ConclusionsOur study confirms that respiratory symptoms often complicate EA and TEF; their persistence despite medical and surgical treatment of GER means that other etiological hypothesis must be examined and that a complete respiratory diagnostic work up must be considered.