Repair Of Tracheoesophageal Fistula Research Articles

Comparison of Modified Pleural Flap Technique vs. Standard Anastomosis for Congenital Tracheo- Esophageal Fistula Repair: A Randomized Control Trial

Background: Tracheoesophageal fistula (TEF) with or without esophageal atresia (EA) is a challenging congenital condition necessitating surgical intervention. The advent of various surgical techniques has sought to improve outcomes and reduce postoperative complications such as anastomotic leakage and stricture formation, which significantly impact neonatal morbidity and mortality. Objective: The aim of this randomized controlled trial was to compare the efficacy of the modified pleural flap technique against the conventional anastomosis technique in the surgical repair of TEF. Methods: Conducted at the Children’s Hospital and Institute of Child Health in Lahore, this study involved 44 full-term neonates, diagnosed with TEF, and weighing over 2 kg. Subjects were randomized into two groups: one receiving the conventional anastomosis (Group A) and the other undergoing the modified pleural flap technique (Group B). Preoperative characteristics, intraoperative details, and postoperative outcomes were meticulously recorded. Statistical analysis was performed using SPSS version 25.0, focusing on the incidence of anastomotic leakage, stricture formation, length of hospital stay, and mortality within 30 days post-surgery. Results: Group B patients experienced significantly lower rates of anastomotic leakage by the 5th postoperative day (9.1%) and 14th postoperative day (13.6%) compared to Group A (36.4% and 40.9%, respectively) with p-values of 0.031 and 0.042. Postoperative stricture formation was also less in Group B (9.1%) compared to Group A (36.4%), with a p-value of 0.031. The mean hospital stay was longer for Group B (27.45 days) compared to Group A (22.09 days), and the mortality rate was lower in Group B, although not statistically significant (p-value = 0.148). Conclusion: The modified pleural flap technique in TEF repair demonstrates a significant reduction in early postoperative complications, offering a promising improvement over the conventional approach. Despite a longer hospital stay, the enhanced outcomes highlight its potential for becoming the preferred surgical intervention for TEF.

Endoscopic repair of tracheoesophageal fistulas: A contemporary multi-institutional case series and literature review

ObjectivesRecurrent and primary tracheoesophageal fistulas (TEFs) are a challenging surgical pathology to treat, as standard open surgical approaches are associated with high morbidity and mortality. As such, endoscopic modalities have gained interest as an alluring alternative, yet variable success rates have been reported in the literature. The aim of this study was to provide a contemporary update of the literature and describe our institutional experience with the bronchoscopic obliteration of recurrent and primary TEFs. MethodsRetrospective chart review of all pediatric patients having undergone endoscopic TEF repair at two pediatric academic centers in Montreal, Canada and Lille, France between January 1, 2008 to December 31, 2020. Results28 patients with TEFs (20 recurrent, 8 primary) underwent a total of 48 endoscopic procedures. TEF repair was performed under endoscopic guidance using various combinations of techniques, including fistula de-epithelialization (endoscopic brush, thulium laser, trichloroacetic acid-soaked pledgets or electrocautery), tissue adhesives, submucosal augmentation, esophageal clip and stenting. Successful closure was achieved in 16 patients (57%), while 12 (43%) required eventual open or thoracoscopic repair. The mean number of endoscopic procedures was 1.7. There were no major treatment-related complications such as pneumothorax, mediastinitis or death (mean follow-up 50.8 months). ConclusionsEndoscopic repair of recurrent or primary TEFs is a valuable component of our therapeutic armamentarium and may contribute to decreased surgical morbidity in this complex patient population. Families should be counselled that endoscopic results may be more modest than with open or thoracoscopic approaches, and multiple procedures may be required.

Difficult Airway Management with Awake Fiberoptic Intubation and Cross Table Ventilation in a Case of Acquired TEF with Severe Subglottic Stenosis

We report a case of 30-year male who presented with Acquired Tracheoesophageal Fistula with subglottic stenosis and Aspiration Pneumonitis. Patient was managed with Feeding Jejunostomy, Tracheoesophageal Fistula repair and Tracheoplasty, after which patient recovered well. Difficult airway was managed by Awake Fiberoptic Intubation and cross-table ventilation through flexometallic tube intraoperatively during TEF repair.

Staged repair of esophageal atresia, tracheoesophageal fistula, and duodenal atresia in a newborn

Staged repair of esophageal atresia, tracheoesophageal fistula, and duodenal atresia in a newborn

Diagnose and treatment for Type D congenital esophageal atresia with tracheoesophageal fistula.

Type D esophageal atresia (EA) with tracheoesophageal fistula (TEF) is characterized by EA with both proximal and distal TEFs. It is a rare congenital anomaly with a very low incidence. To investigate diagnostic and treatment strategies for this rare condition. We retrospectively reviewed the clinicopathological features of patients with EA/TEF treated at our institution between January 2007 and September 2021. Among 386 patients with EA/TEF, 14 (3.6%) had type D EA/TEF. Only two patients were diagnosed with proximal TEF preoperatively. Seven patients were diagnosed intraoperatively. Five patients were missed for diagnosis during the initial surgery but was later confirmed by bronchoscopy. During the neonatal period, seven patients underwent a one-stage repair of proximal and distal TEF via thoracoscopy or thoracotomy. Due to missed diagnosis and other reasons, the other 7 patients underwent two-stage surgery for repair of the proximal TEF, including cervical incision and thoracoscopy. Ten of the 14 patients experienced postoperative complications including anastomotic leakage, pneumothorax, esophageal stricture, and recurrence. Patients who underwent one-stage repair of distal and proximal TEF during the neonatal period showed a higher incidence of anastomotic leak (4/7). In contrast, only one of seven patients with two-stage repair of the proximal TEF developed an anastomotic leak. Type D EA/TEF is a rare condition, and proximal TEFs are easily missed. Bronchoscopy may aim to diagnose and determine the correct surgical approach. A cervical approach may be more suitable for repairing the proximal TEF.

Inanimate 3D printed model for thoracoscopic repair of esophageal atresia with tracheoesophageal fistula.

Thoracoscopic repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF) poses significant technical challenges. This study aimed to develop an inexpensive, reusable, high-fidelity synthetic tissue model for simulating EA/TEF repairs and to assess the validity of the simulator. By using 3D printing and silicone casting, we designed an inexpensive and reusable inanimate model for training in thoracoscopic EA/TEF repair. The objective was to validate the model using a 5-point Likert scale and the Objective Structured Assessment of Technical Skills (OSATS) to evaluate participants' surgical proficiency. A total of 18 participants (7 medical students, 4 pediatric surgery trainees, and 7 experienced surgeons), after being instructed and trained, were asked to perform TEF ligation, dissection, as well as esophageal anastomosis using six sliding knots on the EA/TEF simulator. All participants in the expert group completed the task within the 120-minute time limit, however only 4 (57%) participants from the novice/intermediate completed the task within the time limit. There was a statistically significant difference in OSATS scores for the "flow of task" (p = 0.018) and scores for the "overall MIS skills" (p = 0.010) task distinguishing between novice and intermediates and experts. The simulator demonstrated strong suitability as a training tool, indicated by a mean score of 4.66. The mean scores for the model's realism and the working environment were 4.25 and 4.5, respectively. Overall, the face validity was scored significantly lower in the expert group compared to the novice/intermediate groups (p = 0.0002). Our study established good face and content validity of the simulator. Due to its reusability, and suitability for individual participants, our model holds promise as a training tool for thoracoscopic procedures among surgeons. However, novices and trainees struggled with advanced minimally invasive surgical procedures. Therefore, a structured and focused training curriculum in pediatric MIS is needed for optimal utilization of the available training hours.

S2613 A Case of Endoscopic Repair of Tracheoesophageal Fistula With Septal Occluder Device

S2613 A Case of Endoscopic Repair of Tracheoesophageal Fistula With Septal Occluder Device

Comparing Opioid with Opioid-free Anesthesia Technique in Neonates Undergoing Tracheoesophageal Fistula Repair.

Tracheoesophageal fistula (TEF) is a congenital disorder that presents as a surgical emergency in neonates. In regions where neonatal intensive care unit facilities and resources are inadequate and skilled personnel are scarce, not extubating neonates on table, contributes to mortality. Our aim was to assess and compare the on-table extubation rate, extubation time, and postoperative pain scores between opioid and opioid-free anesthesia techniques in neonates undergoing surgical repair of TEF. We conducted a prospective, single-blind, randomized trial over 18 months between January 2021 and June 2022 in Safdarjung Hospital, New Delhi on 60 full-term neonates scheduled for TEF surgeries randomly allocated to two groups according to the mode of analgesia administered. Group O were given fentanyl injection 1 µg/kg intravenous (IV) loading dose with IV injection. acetaminophen at 7.5 mg/kg and top-up of 0.25 µg/kg fentanyl IV si opus sit. Group NO were given pre-surgical local infiltration and intercostal block with 0.25% and 0.5% bupivacaine, respectively, with IV acetaminophen at 7.5 mg/kg. Mean age in days, gender distribution, and weight in both groups were statistically comparable. The difference in the number of neonates extubated on table was statistically significant (p =0.002) in group NO compared to group O. Lower mean extubation time was seen in group NO (9.0 min 40.0 secs±3.0 min 3.0 secs) compared to group O (16.0 min 45.0 secs±8.0 min 5.0 secs) (p < 0.001). There was a statistically significant (p =0.010) lower Neonatal Infant Pain Scale score in group NO with mean and SD as 1.8±0.8 compared with group O, 2.5±1.1 at 90 min. In neonates undergoing TEF repair, opioid-free anesthesia is a safe and effective method, providing a better extubation rate, faster time to extubation, and better postoperative pain control.

Congenital tracheoesophageal fistula: An anesthetic challenge

Managing a patient scheduled for congenital tracheoesophageal fistula (TEF) repair is challenging for the anesthetist. If an appropriate ventilation strategy is not employed, serious complications such as hypoxemia, gastric distension, and pulmonary aspiration can occur. We present the case of a 2-day-old male child, suffering from an isolated TEF without esophageal atresia (type H) scheduled for an open surgical repair performed by transthoracic approach (right thoracotomy). We successfully managed this intervention and herein report this case to demonstrate the multiple pre-operative, intraoperative, and post-operative complications regarding intubation that can occur while managing such a case.

Morbidity and mortality among neonates with esophageal atresia and/or tracheoesophageal fistula in the United States.

Although rare, esophageal atresia (EA) and/or tracheoesophageal fistula (TEF) can lead to severe morbidity and mortality. A known complication of EA and/or TEF repair is vocal fold motion impairment (VFMI). To characterize the prevalence of VFMI among repaired EA and/or TEF at a national level and to identify factors associated with in-patient mortality and common clinical endpoints in this population (tracheostomy and gastrostomy tube dependence). This is a retrospective cohort study of inpatient neonate admissions with EA and/or TEF in the 2016 Kids' Inpatient Database (KID). Patients with a history of EA and/or TEF were identified with ICD-10 codes. VFMI prevalence was assessed by observed frequencies and percentages. Clinical endpoints included gastrostomy (G-)tube placement, tracheostomy status, and inpatient mortality. Potential predictors of these three primary outcomes included cardiac anomalies, airway disorders, chromosomal anomalies, surgery within 24h of admission, prematurity, and low birthweight (LBW). Chi-squared analysis was performed between each parameter and the primary outcomes. Significant associations (p-value<0.05) were further assessed with multivariate logistic regression. Of 1062 neonates with history of EA and/or TEF, 24 (2.3%) had VFMI. Among this population, 27 patients underwent tracheostomies and 63 required G-tubes. There was a significantly higher likelihood of tracheostomy in patients with VFMI compared to patients without (16.7% versus 2.2%; p<0.01). After multivariate analysis, birthweight less than 1.5kg (BW<1.5kg; OR=2.5, 95% CI: 1.03-6.10), extreme prematurity (OR=7.5, 95% CI: 2.00-28.07), cardiac anomalies (OR=1.8, 95% CI: 1.01-3.04) and chromosomal anomalies (OR=4.2, 95% CI: 2.39-7.44) were significantly associated with in-hospital mortality. Bronchopulmonary dysplasia (BPD; OR=4.7, 95% CI: 1.73-12.78) and BW<1.5kg (OR=2.4, 95% CI: 1.05-5.49) were significant predictors for G-tube status. For tracheostomy, BPD (OR=15.8, 95% CI: 4.70-52.83) and subglottic stenosis (SS, OR=11.2, 95% CI: 1.85-68.02) remained significant predictors after multivariate regression. The national prevalence of VFMI among neonates following EA and/or TEF repair was 2.3% and was associated with an increased likelihood of tracheostomy in the KID 2016. Significant predictors of in-hospital mortality were cardiac anomalies, chromosomal anomalies, extreme prematurity, and BW<1.5kg. BPD and SS were significant predictors of tracheostomy, and BPD and BW<1.5kg were significant predictors for G-tube requirements.

Use of an autologous dermal flap and rib cartilage graft in the repair of a large tracheoesophageal fistula with tracheal stenosis.

Management of large tracheoesophageal fistulas complicated by tracheal stenosis remains challenging as it requires an ideal replacement for the membranous defect as well as a permanent buttress to reconstruct the stenotic segment. We present the successful use of an autologous free dermal flap reinforced with a pedicled pectoralis major muscle to repair the tracheal membranous wall and a rib cartilage graft to enlarge the tracheal lumen.

Risk factors and outcomes associated with unplanned intraoperative extubation of the pediatric surgical patient: An analysis of the NSQIP-P database.

Unplanned intraoperative extubation is a rare but potentially catastrophic safety event. Inadvertent extubation in the neonatal and pediatric critical care setting is a recognized quality improvement metric whereas literature for intraoperative extubation is scarce. The aim of this study was to identify risk factors and outcomes associated with unplanned intraoperative extubation. We queried the National Surgical Quality Improvement Program-Pediatric database from 2019 to 2020 for patients <18 years of age. A total of 253 673 patients were included in the analysis. Associations between demographics, clinical variables, and unplanned intraoperative extubation were evaluated with univariable and multivariable logistic regression models. The primary outcome was unplanned intraoperative extubation. Secondary outcomes were postoperative pulmonary complication, unplanned reintubation within 24 h, cardiac arrest on day of surgery, and surgical site infection. Unplanned intraoperative extubation occurred in 163 (0.06%) patients. Specific procedures experienced unplanned intraoperative extubation at a higher rate such as bilateral cleft lip repair (1.31% of procedure type) and thoracic repair of tracheoesophageal fistula (1.11% of procedure type). Age, operative time (z-score), American Society of Anesthesiologists Classification 3 and 4, neurosurgery, plastic surgery, thoracic surgery, otolaryngology, and structural pulmonary/airway abnormalities were independent risk factors. Unplanned intraoperative extubation was associated with an increased unadjusted risk for postoperative pulmonary complication (p < .005; OR, 6.05; 95% confidence interval [CI]: 1.93-14.44), unplanned reintubation within 24 h (p < .005; OR, 8.41; 95% CI: 2.08-34.03), cardiac arrest on day of surgery (p < .05; OR, 22.67; 95% CI: 0.56-132.35), and surgical site infection (p < .0005; OR, 3.27; 95% CI 1.74-5.67). Unplanned intraoperative extubation occurs at a higher frequency in a subset of procedures and patient types. Identifying and targeting at-risk patients with preventative measures may decrease the incidence of unplanned intraoperative extubation and its associated outcomes.

EE554 Budget Impact Analysis of Intravenous Acetaminophen in Neonates after Esophageal Atresia and Tracheoesophageal Fistula Repair

The primary outcome of this study was to compare the budget impact of intravenous acetaminophen (IV APAP) in combination with opioids versus opioids alone as a pain management strategy after neonatal esophageal atresia (EA) and tracheoesophageal fistula (TEF) repair.

ARE LOW BIRTH WEIGHT AND MAJOR CONGENITAL HEART DISEASES CONTRAINDICATIONS FOR THORACOSCOPIC REPAIR OF ESOPHAGEAL ATRESIA WITH TRACHEOESOPHAGEAL FISTULA?

BACKGROUND Thoracoscopic repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) is becoming an increasingly widespread technique; there is still controversy about its indication in certain patients. Our objective is to analyze if potential risk factors such as major congenital heart disease (CHD) or low birth weight are a limitation to this approach. METHODS Retrospective study (2017-2021) of patients with EA and distal TEF who underwent thoracoscopic repair were included. Patients with low birth weight <2000g or major congenital heart disease were compared to the rest. RESULTS Twenty-five patients underwent thoracoscopic surgery. Nine patients (36%) had major CHD. Five of them (20%) were low birth weight <2000g and only 8% presented both risk factors (2/25). There were no differences in terms of operative time, conversion rate, tolerance evaluated with gasometric parameters (pO2, pCO2, pH) or complications (anastomotic leak and stricture, both early or during follow-up) in patients with major CHD and LBW (1473 ± 319g vs 2664 ± 402g). One conversion to thoracotomy was performed in a baby weighing 1050 g due to anesthetic intolerance. There was no recurrence of TEF. One patient died at the age of 9 months, due to major uncorrectable heart disease. CONCLUSIONS Thoracoscopic repair of EA/TEF is feasible technique in patients with CHD or LBW, with similar results to other patients. The complexity of this technique warrants individualizing the indication in each case.

Tracheo-esophageal fistula repair in a positive COVID-19 patient: use of intercostal muscle flap.

Tracheo-esophageal fistula repair in a positive COVID-19 patient: use of intercostal muscle flap.

Anastomotic time was associated with postoperative complications: a cumulative sum analysis of thoracoscopic repair of tracheoesophageal fistula in a single surgeon's experience.

This study aimed to evaluate the learning curve of thoracoscopic repair of tracheoesophageal fistula (TEF) by a single surgeon using a cumulative sum (CUSUM) analysis. Prospective clinical data of consecutive Gross type-C TEF repairs performed by a pediatric surgeon from 2010 to 2020 were recorded. CUSUM charts for anastomosis and operating times were generated. The learning curves were compared with the effect of accumulation based on case experience. For 33 consecutive cases, the mean operative and anastomosis times were 139 ± 39min and 3137 ± 1110s, respectively. Significant transitions beyond the learning phase for total operating and anastomosis times were observed at cases 13 and 17. Both the total operating time and anastomosis time were significantly faster in the proficiency improvement phase than in the initial learning phase. Postoperative complications significantly decreased after the initial anastomosis learning phase but not after the initial total operating learning phase. Thoracoscopic repair of TEF is considered safe and feasible after 13 cases, where the surgeon can improve their proficiency with the total operation procedure, and 17 cases, which will enable the surgeon to achieve proficiency in anastomosis. Postoperative complications significantly decreased after gaining familiarity with the anastomosis procedure through the learning phase.

Tracheoesophageal fistula treated with magnetic compression technique in canines

There are various surgical methods for tracheoesophageal fistula; however, there is presently no unified standard. Based on the magnetic compression technique, we designed a novel method for the treatment of tracheoesophageal fistula. The purpose of this study was to verify its feasibility in an animal experiment. Six beagle dogs underwent surgical repair after constructing a tracheoesophageal fistula model. After the tracheal and esophageal spaces were freed during the operation, two magnets were used to clamp the fistula. The operation time, intraoperative blood loss, postoperative complications, and wound healing were monitored. Samples were obtained 14 days after the operation, and fistula repair was observed. The tracheoesophageal fistula repair operation was successfully completed for all six beagles. The average operation time was 23.67 ± 4.50 min. The average intraoperative blood loss was less than 10 mL. One dog had a postoperative wound infection, and the rest had no postoperative complications. The wound healed well. In all dogs, after specimen collection, it was observed that the fistula was successfully closed and the mucosal layer was smooth and flat. Histological observation showed that the anastomosis was slightly inflamed, the mucosal layer and surrounding tissues were arranged neatly, and the structure was slightly disordered. Magnetic compression technique can be effectively used to repair tracheoesophageal fistula, shorten the operation time, and simplify the operation procedure, and thus, it has the potential for clinical application.

Surgical management of large tracheoesophageal fistula in infants after button battery ingestion.

In recent years, an increase in severe and even fatal outcomes related to oesophageal or airway button battery (BB) ingestion by infants and small children has been reported. Extensive tissue necrosis caused by lodged BB can lead to major complications, including tracheoesophageal fistula (TEF). In these instances, best treatment remains controversial. While small defects may warrant a conservative approach, surgery often remains inevitable in highly complex cases with large TEF. We present a series of small children that underwent successful surgical management by a multidisciplinary team in our institution. This is a retrospective analysis of n = 4 patients <18 months undergoing TEF repair from 2018 to 2021. Surgical repair under extracorporeal membrane oxygenation (ECMO) support was feasible in n = 4 patients by reconstructing the trachea with decellularized aortic homografts that were buttressed with pedicled latissimus dorsi muscle flaps. While direct oesophageal repair was feasible in 1 patient, 3 required esophagogastrostomy and secondary repair. The procedure was completed successfully in all 4 children with no mortality and acceptable morbidity. Tracheo-oesophageal repair after BB ingestion remains challenging and is associated with major morbidity. Bioprosthetic materials in conjunction with the interposition of vascularized tissue flaps between trachea and oesophagus appear to be a valid approach to manage severe cases.

Longitudinal Force Measurement and its Relationship to Technical Competence for Esophageal Anastomosis in a Thoracoscopic Esophageal Atresia/Tracheo-Esophageal Fistula Simulator

PurposeThoracoscopic esophageal atresia with tracheo-esophageal fistula (EA/TEF) repair requires the gentle manipulation of delicate tissue. Force sensors were attached to the upper and lower esophagus of a 3D-printed EA/TEF simulator to explore force parameters as markers of performance. MethodsParticipants completed one intracorporeal suture between the anterior walls of upper and lower esophageal ends. Longitudinal force data were recorded at each end. A blinded pediatric surgeon marked attempt videos. Excessive force events, maximum tension, and force interquartile range (IQR) were measured. Data were reported as median (range) significance of p < 0.05. Results17 participants of varying levels of experience performed the task. OSATS scores showed significant differences between experts and novices. Experts completed the task in a median time of 4 min. They used lower maximum tension, higher force IQR, and had fewer excess force events compared to the intermediate and novice groups. DiscussionThe application of force was dependent on expertise with more skilled participants having fewer excess force events. The higher expert force IQR likely reflects the consistent tension needed for task completion. Analysis of force data may be an indicator of competence, and trainees may benefit from a thoracoscopic simulator which provides force data feedback. Level of evidenceNot applicable.

S2265 A Rare Case of Esophageal Carcinoma After Tracheoesophageal Fistula Repair

Introduction: Tracheoesophageal fistula (TEF) constitutes one of the commonest congenital anomalies with an incidence of roughly 1 in 3500 births with treatment consisting of surgical correction in very early life. Chronic complications can include esophageal stricture, dysphagia, gastroesophageal reflux disease (GERD), Barrett’s esophagus, and esophageal cancer. While rare, these patients do have an increased risk of esophageal carcinoma attributable to chronic GERD leading to ongoing mucosal disruption. Sparce data on esophageal cancer after TEF repair appears to show an increased risk of this event occurring after 40 years of age. Case Description/Methods: The patient is a 32-year-old man with a past medical history of Cystic Fibrosis, GERD, osteoporosis, and tobacco use, and a past surgical history significant for Tracheoesophageal fistula repair. The patient presented to a primary care physician with complaints of dysphagia. He reported dysphagia only to liquids that started 2 months before presentation. The dysphagia was gradually progressed to solids. He was referred to gastroenterology, and an EGD was performed showing a single traversable mass measuring 5 cm in the esophagus (20 cms. from incisors) covering one-quarter of the circumference, and cold forceps biopsy was performed. The EGD also revealed signs of the previous tracheoesophageal fistula repair and mild generalized atrophic mucosa. Biopsies taken from the esophagus and stomach were sent for pathology. Pathology from the esophageal biopsy came back positive for moderately differentiated Squamous cell carcinoma and gastric biopsy revealed chronic gastritis with complete intestinal metaplasia. The patient was referred to oncology and underwent a PET scan which revealed the esophageal malignancy and bilateral pulmonary nodules. The patient was started on chemoradiation therapy and follows up with oncology regularly (Figure). Discussion: This case describes the importance of continuity of care during the transition from pediatrics to adult care in the field of gastroenterology in patients with a history of TEF repair, given the patient’s young age. While it appears esophageal cancer after TEF repair is rare, there should be an investigation into guidelines for adequate screening in this disease process.Figure 1.: Histopathology and endoscopic images.