Repair Of Tracheoesophageal Fistula Research Articles

Re: Infantile Hypertrophic Pyloric Stenosis following Repair of H-type Tracheoesophageal Fistula Repair and Post-operative Erythromycin Therapy

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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.

Repair of Adult Benign Tracheoesophageal Fistulae With Absorbable Patches: Single-Center Experience

This group previously reported on the repair of a wide tracheoesophageal fistula with a bioabsorbable patch. The current study describes a consecutive series of patients operated on using the same technique. Data of patients undergoing surgical closure of tracheoesophageal fistula at a single center from 2011 to 2018 were extracted and analyzed. An absorbable patch was used in 8 of 23 patients (34.8%) operated on for tracheoesophageal fistula during the study period. Causes of the fistulae included postintubation injury (n= 6), mediastinal radiotherapy (n= 1), and a complication of lung resection (n= 1). The median fistula size was 27.5 mm (range, 15 to 45 mm). In 3 patients, the surgical approach was through cervicotomy and in 5 it was through right thoracotomy. Prosthetic materials consisted of Gore Bio-A (W.L. Gore & Associates, Inc, Newark, DE) tissue reinforcement in 6 patients and polyglactin 910 knitted mesh in 2 patients. In every case, the prosthesis was covered with a pedicled muscle flap. The esophageal defect was treated by primary closure in 7 patients and by esophageal exclusion in 1. Fistula recurrence and postoperative death occurred in 1 patient (12.5%), whereas 7 patients experienced postoperative complications (87.5%). Five patients resumed oral intake, and 3 breathed without a tracheal appliance. Compared with the other patients, in those who underwent repair of their fistula using a prosthesis, the median size of the airway defect was larger, morbidity was greater, and the rate of resumption of oral intake was lower. Repair of tracheoesophageal fistulae with synthetic prostheses is feasible and may be effective in complex cases. Further research is needed to identify the ideal prosthetic material.

Thoracoscopic versus conventional open repair of tracheoesophageal fistula in neonates: A short-term comparative study

PurposeEsophageal atresia with or without a tracheo-esophageal fistula is a challenging anomaly in neonates. Thoracoscopic repair is gaining popularity now in pediatric surgery community. The present study aims at comparing the short term outcomes of thoracoscopy versus classic thoracotomy for repair of such conditions. MethodsThirty neonates with tracheoesophageal fistula were randomly divided into two equal groups (n=15) after excluding patients with birth weight <2000g, multiple associated anomalies and cardiorespiratory instability. One group had conventional open repair while the other had thoracoscopic repair. Demographic data, intraoperative result and post-operative findings were recorded and compared between both groups. ResultsBoth groups showed similar results regarding demographic and patients’ characteristics. Thoracoscopic repair had relatively longer, yet non-significant operative time but with highly significant difference in preserving azygos vein. There was low conversion rate with thoracoscopy (6.66%). Open repair resulted in a longer hospital stay (11.73±5.68 vs 9.2±2.95). Complication rate was comparable in both groups; however, thoracoscopy was associated with better cosmetic results as reported by parents and surgeons (p=0.00). ConclusionCompared to thoracotomy, thoracoscopic repair offers a less invasive, effective and safe technique with similar short term outcomes, but with superior cosmetic results and better ability to spare azygos vein. Type of StudyTherapeutic/Treatment study Level of EvidenceLevel II

Novel Use of Pleural Sealant for Repair of Tracheal Defects and Tracheoesophageal Fistula

Mohammad, Benefsha MD; Sharma, Ishna MD; Jensen, Todd MHS; Finck, Christine MD, FACS; Weiss, Daniel MD, PhD Author Information

1758 H-type Tracheoesophageal Fistula: A Rare Cause of Cough and Dysphagia in Adults

INTRODUCTION: Tracheoesophageal fistula (TEF) without associated esophageal atresia (H-type) is a rare congenital anomaly, accounting for ∼4% of esophageal malformations. It is defined as a connection between the posterior tracheal and anterior esophageal walls and is typically diagnosed before age 3. However, it can occasionally be seen in adults with chronic cough and respiratory infections. We present a 38-year-old female with a new diagnosis of H-type TEF. CASE DESCRIPTION/METHODS: A 38-year-old female (G16P12-0-3-12) with multiple prior admissions for hypoxia (presumed due to asthma and aspiration in the setting of achalasia) was admitted with HELLP syndrome. Prior pulmonary function tests showed severe airway obstruction and echocardiogram showed normal left and right ventricular systolic function. She reported coughing when supine and with meals, a history of congenital lung abnormality, severe infancy pneumonia, upper lobe resection, diagnosis of achalasia, and yearly admissions for pulmonary issues. After delivery, she was transferred to the pulmonary service for management of her hypoxia. A TEF without inflammation was noted on chest CT and confirmed by EGD and bronchoscopy. EGD showed a 3 mm proximal esophageal fistula. Bronchoscopy demonstrated a normal oropharynx and vocal cords (VC), erythematous larynx, inflamed arytenoids, a 4 mm proximal TEF without mucosal abnormalities, and right upper lobe (RUL) absence. A swallow study showed aspiration on the posterior side of the trachea presumed due to the TEF. Surgical repair rather than endoscopic clip or stent placement was determined to be the best treatment via cervical approach esophagoplasty, muscle flap reconstruction TEF repair, and laparoscopic Heller myotomy with Dor fundoplication. DISCUSSION: H-type TEF is rare and can mimic chronic lung disease due to aspiration, recurrent infection, and bronchiectasis. It must be considered in adults with recurrent respiratory infections, coughing with eating/drinking, and rarely, hemoptysis. A chest CT, bronchoscopy, esophagoscopy, and barium study are crucial to confirm the diagnosis. While endoscopic clip closure of fibrotic TEFs has been successful in 62%, it may obliterate surgical tissue planes. Surgery is the optimal treatment for H-type TEF and reported to be 75-94% successful. As H-type TEF disrupts myenteric plexus development with impaired esophageal peristalsis and lower sphincter dysfunction, a Heller myotomy and Dor fundoplication should be offered.

Thoracoscopy vs. thoracotomy for the repair of esophageal atresia and tracheoesophageal fistula: a systematic review and meta-analysis.

Esophageal atresia (EA) and tracheoesophageal fistula (TEF) require emergency surgery in the neonatal period to prevent aspiration and respiratory compromise. Surgery was once exclusively performed via thoracotomy; however, there has been a push to correct this anomaly thoracoscopically. In this study, we compare intra- and post-operative outcomes of both techniques. A systematic review and meta-analyses was performed. A search strategy was developed in consultation with a librarian which was executed in CENTRAL, MEDLINE, and EMBASE from inception until January 2017. Two independent researchers screened eligible articles at title and abstract level. Full texts of potentially relevant articles were then screened again. Relevant data were extracted and analyzed. 48 articles were included. A meta-analysis found no statistically significant difference between thoracoscopy and thoracotomy in our primary outcome of total complication rate (OR 0.98, [0.29, 3.24], p = 0.97). Likewise, there were no statistically significant differences in anastomotic leak rates (OR 1.55, [0.72, 3.34], p = 0.26), formation of esophageal strictures following anastomoses that required one or more dilations (OR 1.92, [0.93, 3.98], p = 0.08), need for fundoplication following EA repair (OR 1.22, [0.39, 3.75], p = 0.73)-with the exception of operative time (MD 30.68, [4.35, 57.01], p = 0.02). Considering results from thoracoscopy alone, overall mortality in patients was low at 3.2% and in most cases was due to an associated anomaly rather than EA repair. Repair of EA/TEF is safe, with no statistically significant differences in morbidity when compared with an open approach.Level of evidence 3a systematic review of case-control studies.

Survival outcomes of trachea esophageal fistula in infant

Background: Tracheo-esophageal fistula (TEF) is a rare congenital abnormality often associated with several other anomalies including renal, vertebral column, gastrointestinal or cardiovascular defects. This study was carried out to evaluate the outcome of trachea esophageal fistula among patients who underwent various surgeries for the anastomosis of trachea esophageal fistula.Methods: This study was conducted as a record based cross sectional study among 88 patients who were diagnosed and treated for trachea-esophageal fistula in tertiary care hospital between 2015 and 2018. Data regarding the type of anomaly, presence of associated anomalies, type of surgery and outcomes were documented. Findings of echocardiography and ultrasonography were also documented. Data was analyzed using SPSS software. Chi square test was used to evaluate the outcome of the surgical procedures for management of TEF.Results: Majority of the participants in our study belong to &lt;1 month of age and were males (56.8%). Type 3 tracheo esophageal fistula (80.7%) was the most common type. Associated cardiovascular anomalies were present in 50% of the participants. Thoracotomy with TEF repair was most preferred surgery (76%). Present study demonstrated that surgical techniques improve the physical and physiological outcome of the patients (p &lt;0.05).Conclusions: Trachea esophageal fistula needs to be corrected with surgical procedure. Modern techniques like thorocoscopic anastomosis, thorocosopic techniques to achieve an anastomosis can also be explored. Future studies may be directed in detecting congenital anomalies during the pre-natal period with the help of genetic techniques.

Thoracoscopic Posterior Tracheopexy Is a Feasible and Effective Treatment for Tracheomalacia.

Background: Posterior tracheomalacia is characterized by collapsibility of the posterior trachea and is often present in patients with congenital esophageal atresia (EA) with or without tracheoesophageal fistula (TEF). It can lead to a variety of symptoms from mild expiratory stridor and difficulty clearing secretions to severe respiratory distress, especially in the setting of increased work of breathing. Depending on the severity of symptoms, treatment ranges from medical therapy, including airway clearance techniques, aerosolized medications, and steroids to surgical treatment. The purpose of this study is to review our institution's experience with posterior tracheopexy. Materials and Methods: A retrospective review was conducted from 2017-2019 at a freestanding quaternary care children's hospital. Results: The analysis included 8 patients. The median age at surgery was 6 (range 3-8) years and 4 (50%) of cohort were male. The majority of patients (n = 6, 75%) had a history of prior EA and TEF repair and 3 (38%) had associated VACTERL anomalies. All patients demonstrated severe tracheomalacia on preoperative bronchoscopy with collapse of the posterior membrane. In regard to surgical approach, most cases (6/8, 75%) underwent thoracoscopic repair. The median operative time was 218 (193 thoracoscopic, 218 open) minutes. The median length of stay was 3 days, and 2 (25%) patients had a postoperative complication of chylothorax (1 thoracoscopic and 1 open), both of which resolved without invasive intervention. The current median length of follow-up is 3 months, and all patients reported symptomatic improvement. One patient who had initial symptomatic improvement has undergone repeat tracheopexy for recurrence. Conclusion: Posterior tracheopexy is an effective treatment option for symptoms associated with tracheomalacia. The thoracoscopic approach is feasible in experienced hands and with the support of a multidisciplinary team.

Clinical efficacy of magnetic compression anastomosis for congenital esophageal atresia and stenosis

Objective To investigate the clinical efficacy of magnetic compression anastomosis for congenital esophageal atresia and stenosis. Methods The retrospective and descriptive study was conducted. The clinical data of 4 children who underwent magnetic compression anastomosis for congenital esophageal atresia and stenosis in the Northwest Women and Children′s Hospital from December 2017 and February 2019 were collected. There were 2 males and 2 females. The children were aged 11 days, 7 days, 5 days, and 3 years, respectively. The children underwent magnetic compression anastomosis. Observation indicators: (1) surgical and postoperative situations; (2) follow-up. Follow-up using outpatient examination and telephone interview was performed to detect food intake and complications of children up to May 2019. Measurement data with normal distribution were represented as Mean±SD, and measurement data with skewed distribution were represented as M (range). Results (1) Surgical and postoperative situations: four children underwent magnetic compression anastomosis successfully. Of the 4 children, 3 with esophageal atresia underwent open tracheoesophageal fistula repair and endoscope-assisted magnetic compression anastomosis, and 1 with congenital esophageal stenosis underwent endoscopic gastrostomy combined with magnetic compression anastomosis. The operation time of 4 children was (2.3±0.9)hours. The length of esophageal blind ending in the 3 children with esophageal atresia and length of esophageal stenosis were in the children with esophageal stenosis 30-35 mm and 8 mm. Four children has good magnet apposition, and time of postoperative magnet removal was (29±10)days. Three children with esophageal atresia had oral removal of magnet, and 1 with esophageal stenosis had magnet removed by gastrostomy. One child complicated with postoperative fistula and anastomotic stenosis was cured by unobstructed drainage and nutritional support treatment. The duration of postoperative hospital stay was (39±10)days. (2) Follow-up: 4 patients were followed up for 3-17 months, with a median time of 10 months, and restored to oral intake after oral removal of magnet and removal of magnet by gastrostomy on the days 14-36 postoperatively. One child was detected anastomotic stenosis by esophagography at the postoperative 3 months, and was improved after esophageal dilatation. The other 3 children recovered to normal connectivity of esophagus postoperatively and maintain unobstructed. Four children had normal eating, without dysphagia or other serious complications. Conclusion Magnetic compression anastomosis is safe and feasible for congenital esophageal atresia and stenosis, with good short-term efficacy. Key words: Congenital esophageal atresia; Congenital esophageal stenosis; Magnetics; Surgical instruments; Anastomosis

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.

A multicenter audit of the use of bronchoscopy during open and thoracoscopic repair of esophageal atresia with tracheoesophageal fistula.

Esophageal atresia (EA) with tracheoesophageal fistula is usually repaired in the neonatal period. Preferential ventilation through the fistula can lead to gastric distension. Bronchoscopy has a role in defining the site and size of the fistula, and may be carried out by the surgeon or the anesthetist. The use of bronchoscopy varies across different institutions. This is a multicenter case note review of infants with EA with tracheoesophageal fistula who underwent surgery between January 2010 and December 2015. This retrospective audit aims primarily to document the use of bronchoscopy during open and thoracoscopic repair at a selection of United Kingdom centers. Respiratory complications, that is relating to airway management, the respiratory system, and difficulty with ventilation, at induction and during surgery,are recorded. The range of techniques for anesthesia and analgesia in these centers is noted. Bronchoscopy was carried out in 52% of cases. The incidence of respiratory complications was 7% at induction and 21% during surgery. Thoracoscopic repair usually took longer. One center used high-frequency oscillatory ventilation, on an elective basis during thoracoscopic repair, to facilitate surgical access and address concerns about hypoxemia and hypercarbia. The use of bronchoscopy varies considerably between institutions. Infants undergoing tracheoesophageal fistula repair are at risk of perioperative respiratory morbidity. The advent of thoracoscopic repair has introduced further variation.

Open Surgical Repair of Congenital Esophageal Atresia and Tracheoesophageal Fistula by Azygos Spring versus Classic Repair

Open Surgical Repair of Congenital Esophageal Atresia and Tracheoesophageal Fistula by Azygos Spring versus Classic Repair

Infantile Hypertrophic Pyloric Stenosis Following Repair of H-type Tracheoesophageal Fistula Repair and Post-operative Erythromycin Therapy

We present a rare case of a newborn with H-type tracheoesophageal fistula (TEF) who developed pyloric stenosis postoperatively, 10 days after he was started on erythromycin to promote gastric emptying. We report this case to describe the relationship between H-type TEF repair, erythromycin therapy, and the development of infantile hypertrophic pyloric stenosis.

Infantile Hypertrophic Pyloric Stenosis Following Repair of H-type Tracheoesophageal Fistula Repair and Post-operative Erythromycin Therapy

We present a rare case of a newborn with H-type tracheoesophageal fistula (TEF) who developed pyloric stenosis postoperatively, 10 days after he was started on erythromycin to promote gastric emptying. We report this case to describe the relationship between H-type TEF repair, erythromycin therapy, and the development of infantile hypertrophic pyloric stenosis.

Airway concerns in a neonate with Treacher Collins syndrome posted for tracheoesophageal fistula repair

Airway concerns in a neonate with Treacher Collins syndrome posted for tracheoesophageal fistula repair

Prevalence and Predictive Factors of Histopathological Complications in Children with Esophageal Atresia.

Endoscopic follow-up after esophageal atresia (EA) tracheoesophageal fistula (TEF) repair is recommended to detect esophageal histopathological complications. We investigated the prevalence of histopathologically proven esophageal complications (peptic esophagitis, gastric metaplasia, and eosinophilic esophagitis) and assessed the predictors of these complications in children with EA-TEF. This is a prospective longitudinal cohort study performed between September 2005 and December 2014 comprising 77 children with EA-TEF followed-up until February 2017. Univariate analysis was performed using the Wilcoxon's rank-sum test for continuous variables and the Pearson's chi-square test for categorical variables. Multivariable analysis was performed using a Cox regression hazard model. The association between clinical factors and histopathologically proven complications was estimated using a Cox regression hazard model with time until the appearance of complications as the time scale. All 77 children received proton pump inhibitors (PPIs) (n = 73) or H2 receptor antagonists (H2RA). A total of 252 endoscopies were performed in 73 children (median 2.6/child, range: 1-29). Median age at study completion was 4.9 years (range: 2.3-11.5 years). Histopathologically proven complications occurred in 38 children (52%): peptic esophagitis (n = 32, 44%), eosinophilic esophagitis (n = 15, 21%), and gastric metaplasia (n = 9, 12%). A total of 82% patients were on PPI or H2RA at the time of diagnosis of histological complication. Multivariable Cox regression analysis showed that patients with recurrent anastomotic strictures (>3 dilations) had a higher risk of occurrence of histopathologically proven complications over time (hazard ratio: 3.11, 95% confidence interval [CI]: 1.53-6.34). On univariate analysis, the result of the first endoscopy was not associated with the occurrence of histopathologically proven complications (odds ratio: 0.8, 95% CI: 0.16-3.95). Histopathologically proven complications with potential long-term consequences occurred in approximately 50% of children after EA-TEF repair. A history of recurrent anastomotic strictures is associated with the occurrence of these complications. The result of the first endoscopy does not predict the histopathological outcome. Children with EA-TEF warrant close and systematic long-term follow-up at specialized multidisciplinary clinics with endoscopic evaluation.

Primary Posterior Sagittal Anorectoplasty and Repair of Esophageal Atresia with Tracheoesophageal Fistula in the Same Sitting

Esophageal atresia and tracheoesophageal fistula is often associated with anorectal malformation. Traditionally, staged surgeries are performed in this condition. We did a successful repair of esophageal atresia and tracheoesophageal fistula and primary posterior sagittal anorectoplasty for anorectal malformation in the same sitting.

Vocal cord dysfunction following esophageal atresia and tracheoesophageal fistula (EA/TEF) repair

BackgroundThe purpose of this study was to determine risk factors and long-term outcomes in patients with esophageal atresia +/−tracheoesophageal fistula (EA/TEF) with vocal cord dysfunction (VCD) owing to recurrent laryngeal nerve (RLN) injury. MethodA retrospective chart review was performed for EA/TEF patients repaired at our institution from 1999 to 2014 (REB #1000032265). ResultsOf 197 patients, 22 (11.2%) were diagnosed with VCD by indirect laryngoscopy following EA/TEF repair. Aspiration was documented on video swallow study for 21 patients, and as a result, 13 required thickened feeds and 8 required gastrostomy tube feeds. Of the 16 H-type TEF patients, 8 (50%) had VCD. Following discharge, 20 (90.9%) patients with VCD eventually tolerated full feeds orally without aspiration but only 8 (36.4%) had documented recovery of vocal cord movement at long-term follow up (mean 452 days). Overall, patients with VCD were more likely to have feeding modifications, increased exposure to radiological studies, and increased frequency of Otolaryngology follow-up compared to EA/TEF patients without VCD. ConclusionEA/TEF patients are at risk for VCD. Clinical improvement did not always correlate with recovery of VC motion. Strategies to minimize RLN damage will improve outcomes and quality of life for EA/TEF patients. Level of evidenceLevel III.

Total Parenteral Nutrition Lipid Emulsion Pleural and Pericardial Effusions May Present Similar Chylothorax with Milky White Chest Tube Output after Tracheoesophageal Fistula Repair

Total Parenteral Nutrition Lipid Emulsion Pleural and Pericardial Effusions May Present Similar Chylothorax with Milky White Chest Tube Output after Tracheoesophageal Fistula Repair