Temporary stenting of acquired benign tracheoesophageal fistulas in critically ill ventilated patients

Acquired Non-malignant Cervical Trachea-Esophageal Fistula: A Case Series

Acquired non-malignant trachea-esophageal fistula (TEF) of cervical oesophagus is rare. Surgical closure of fistula is the standard treatment of choice. Our experience in management of such cases is presented. Five cases of acquired cervical TEF of varying etiology were retrospectively analysed. Two patients had history of migrated endoluminal stent. All the patients were treated by trans-cervical repair with muscle interposition. Tracheal Stenosis in two patients was managed concurrently. Successful repair was achieved in four cases. One patient with chronic obstructive pulmonary disease and active leprosy has residual fistula. Of the two patients with tracheal stenosis correction one was decannulated 6 month later and second has stent in situ. Post-operative vocal cord palsy occurred in one patient. Transcervical repair with muscle interposition is treatment of choice in cases of acquired nonmalignant cervical tracheoesophageal fistulas. Endoluminal stents have high tendency to migrate and are not recommended.

Recent advancements in the minimally invasive management of esophageal perforation, leaks, and fistulae

INTRODUCTION

Historically, the gold standard management of esophageal perforations, leaks, and fistulae has been traditional open surgery, but it is associated with significant morbidity and mortality. Minimally invasive approaches offer alternatives to surgery in treating hemodynamically stable patients with such defects. In this review article, we will discuss the recent advancements in the minimally invasive management of esophageal perforations, leaks, and fistulas.

AREAS COVERED

This review includes information from case reports, case series, and clinical trials on minimally invasive management of esophageal perforations, leaks, and fistulas. The focus is on the devices, outcomes, and application of the technology.

EXPERT COMMENTARY

Minimally invasive treatment represents significant progress in the management of esophageal perforations, leaks, and fistulas. Based on current evidence, it seems safe and effective but it is evolving and more studies are needed to help draw definitive conclusions.

Esophageal bypass surgery as a definitive repair of recurrent acquired benign bronchoesophageal fistula

Background

Acquired benign bronchoesophageal fistula (BEF) is rare and develops as a complication of other diseases, mostly of inflammatory processes and traumas of the chest. The treatment of choice is a surgical repair, which is considered definitive and leads to successful outcomes. However, incidence of recurrence after the primary repair based on limited data is up to 10% and its treatment is challenging. We report a surgical case of a patient with recurrent acquired benign BEF after primary resection and ensuing successful definitive repair with esophageal bypass surgery after temporary esophageal stenting.

Case report

A 46-year-old male was referred to our department with a symptomatic left-sided bronchoesophageal fistula as a complication of severe acute necrotizing mediastinitis that originated from odontogenic abscess. Previously, several cervicotomies and bilateral thoracotomy were performed at an external medical facility to manage the acute condition. We performed resection of the fistula through re-thoracotomy. Postprocedural esophagography demonstrated a recurrence of bronchoesophageal communication. Postinflammatory adhesions excluded further repair through thoracotomy, therefore a stent was introduced in the esophagus for 12 weeks. Thereafter, an esophageal bypass surgery using a substernaly interposed gastric conduit was performed and resulted in an excellent long-term outcome.

Conclusions

Esophageal bypass surgery using a substernaly interposed gastric conduit may be considered if the standard surgical repair of acquired benign bronchoesophageal fistula is not successful or feasible.

A new method of tracheoesophageal fistula treatment: Using an atrial septal defect occluder device for closure-The first Turkish experience

OBJECTIVE

One of the techniques used in the treatment of tracheoesophageal fistula is applying the umbrella catheter, designed for closure of atrial septal defects, in this region. In the literature, we have encountered only 9 case reports in this regard. We shared a successfully closed tracheoesophageal fistula case with this technique.

CASE

A tracheoesophageal fistula in a 47-year-old male patient was successfully closed with an atrial septal defect occluder device. The patient died on the 42nd day after the procedure with no atrial septal defect occluder device-related problems.

CONCLUSION

Using of atrial septal defect occluder device may be an appropriate option for tracheoesophageal fistula treatment. It can be said that the procedure is successful when the device is completely covered. Even so, there is a need for multi-centered, randomized, controlled studies of large series about the subject.

Magnetic Twin Stent for Short-Term Palliation of Acquired Nonmalignant Tracheoesophageal Fistula

Through a tracheostomy with a rigid esophagoscope in the esophagus, the authors simultaneously placed self-made magnetic twin stents in a critically ill patient with high tracheoesophageal fistula. The operation took 17 minutes. Oral nutrition was started immediately. The stents were checked and changed after the months 3, 7, and 14. At 18 months, a tracheal resection and esophageal reconstruction through a partial median sternotomy was completed successfully. The magnetic twin stent technique can temporize critically ill patients with an acquired nonmalignant tracheoesophageal fistula until they become operable.

Repair of challenging non-malignant tracheo- or broncho-oesophageal fistulas by extrathoracic muscle flaps

OBJECTIVES

Evaluation of complex, acquired, non-malignant tracheo/broncho-oesophageal fistulas (TEF) repaired by extrathoracic pedicled muscle flaps that were, in addition to their interposition between the airways and the gastro-intestinal tract, patched into gastro-intestinal or airway defects if primary closure seemed risky.

METHODS

A single institution experience of patients treated between 2003 and 2015. Twenty-two patients required TEF repair following oesophageal surgery (18), Boerhaave syndrome (1), chemotherapy for mediastinal lymphoma (1), carinal resection and irradiation (1) and laryngectomy (1); 64% of them underwent prior radio- or chemotherapy and 50% prior airway or oesophageal stenting.

RESULTS

Airway defects were closed by muscle flap patch ( n  = 12), lobectomy ( n  = 4), airway resection/anastomosis ( n  = 2), pneumonectomy ( n  = 1), segmentectomy ( n  = 2) or primary suture ( n  = 1). Gastro-intestinal defects were repaired by oesophageal diversion ( n  = 9), muscle flap patch ( n  = 8) or primary suture ( n  = 5). A muscle flap patch was used to close airway and gastro-intestinal defects in 55% and 36% of cases, respectively. The 90-day postoperative mortality and TEF recurrence rates were 18% and 4.5%. Airway healing and breathing without tracheal appliance was obtained in 95% of patients and gastro-intestinal healing in 77% of those without oesophageal diversion. Five of nine patients with oesophageal diversion underwent intestinal restoration by retrosternal colon transplants.

CONCLUSIONS

Complex TEF arising after oesophageal surgery, radio-chemotherapy or failed stenting can be successfully closed using extrathoracic muscle flaps that can, in addition to their interposition between the airway and the gastro-intestinal tract, also be patched into gastro-oesophageal or airway defects if primary closure seems hazardous.

History of the Use of Esophageal Stent in Management of Dysphagia and Its Improvement Over the Years

The art and science of using stents to treat dysphagia and seal fistula, leaks and perforations has been evolving. Lessons learnt from the deficiencies of previous models led to several improvements making stent deployment easier, and with some designs, it was also possible to remove the stents if needed. With these improvements, besides malignant dysphagia, newer indications for using stents emerged. Unfortunately, despite several decades of evolution, as yet, there is no perfect stent that "fits all." This article is an overview of how this evolution process happened and where we are currently with using stents to manage patients with dysphagia and with other esophageal disorders.

Repair of large airway defects with bioprosthetic materials

OBJECTIVE

Patients with complicated airway defects that exceed the limits of primary repair represent a challenging clinical problem and require alternative techniques for repair. The aim of this study was to evaluate bioprosthetic reconstruction of large tracheal and bronchial defects.

METHODS

Retrospective chart review of patients treated at a single tertiary center from 2008 to 2015 who underwent repair of tracheal or bronchial defects with a bioprosthetic device, namely aortic homograft or acellular dermal matrix.

RESULTS

Eight patients, 3 men and 5 women with a mean age of 54 ± 13 years, underwent closure of complex central airway defects with bioprosthetic material. All but 1 patient underwent prior operative or stenting procedures. Three patients had isolated airway defects, whereas 5 had fistulas between the airway and enteric tract. Defects involved the membranous wall of the trachea (n = 5), the anterior wall of the trachea (n = 1), or the main stem bronchus (n = 2). Five reconstructions were with aortic homograft and 3 with acellular dermal matrix. Bioprosthetic material was buttressed with muscle flap (n = 4), omentum (n = 2), or left unbuttressed (n = 2). The airway defect was successfully closed in all patients. There was no postoperative mortality or recurrence of the airway defect in short-term follow-up. Two patients required debridement of granulation tissue and 1 additional patient required airway balloon dilation. Progression of underlying metastatic disease explained the majority of long-term mortality (75%).

CONCLUSIONS

Bioprosthetic materials represent a viable option for management of large airway defects, including airway-enteric fistulae, that exceed the limits of primary repair.

Palliation of Concomitant Tracheobronchial and Esophageal Disease Using a Combined Airway and Esophageal Approach

BACKGROUND

Neoplastic involvement of the mediastinum can contribute to both airway and esophageal pathology. That can manifest as combined esophageal and airway stenosis, or tracheobronchoesophageal fistula. Conventional palliative treatment of these problems consists of endoluminal stent insertion. The double stenting approach consists of insertion of a tracheobronchial and an esophageal stent in parallel and allows concomitant symptomatic relief of both the airway and esophageal pathology.

METHODS

The study consists of a retrospective case series of patients who underwent a double stenting procedure for concomitant airway and esophageal disease between August 2009 and September 2014. The type of airway stent chosen was determined based on the pathology and the level of the lesion (simple tubular in the mid trachea or mainstem bronchus, Y-stent for carina).

RESULTS

Thirty-nine patients were treated using the double stenting approach during a combined procedure over 5 years: 15 patients with tracheobronchoesophageal fistula and 24 with stenosis. Immediate relief of symptoms, defined as resuming oral intake and breathing without an external tracheal device, was observed in 25 patients (64%). Thirty-two patients (82%) were discharged from hospital, and 7 patients died in hospital (18%). Of these 7 deaths, 6 patients died of pulmonary complications. Inhospital complications occurred in 11 patients (28%). Of the patients discharged from the hospital, 14 died during a mean follow-up period of 54 days. Mean and median survival were 49 and 24 days, respectively (range, 1 to 448), and median hospital stay was 3 days (range, 1 to 46).

CONCLUSIONS

Treatment of combined airway and esophageal pathology using a double stenting approach is safe, feasible, provides reasonable immediate palliation of symptoms, and is associated with acceptable morbidity. It is a palliative procedure that allows for early hospital discharge of patients who are diagnosed with an incurable malignancy.

Closure of Nonmalignant Tracheoesophageal Fistula Using an Atrial Septal Defect Occluder: Case Report and Review of the Literature

Tracheoesophageal fistula (TEF) is a life-threatening condition for which there are several management techniques. We present a case of nonmalignant TEF closure using an atrial septal defect (ASD) occluder. A 53-year-old man with a severe TEF was admitted to our hospital for TEF caused by stenting of an esophagogastric anastomotic stricture. He was successfully treated with closure of the TEF using an endotracheal ASD occluder. Three hundred and eighteen days after placement of the occluder, he suddenly developed a severe cough after dilatation of the esophagogastric anastomosis and spontaneously coughed out the occluder. The fistula was repaired and complete closure that was confirmed on esophagography. He had no recurrence of fistula during the follow-up period of 13 months.

Pharyngeal perforation and tracheopharyngeal fistula caused by foreign body impaction

Development of a tracheopharyngeal fistula after pharyngeal perforation is an uncommon occurrence. As a result, published guidance for management of this rare type of aerodigestive tract fistula is limited. We describe the workup and management of a traumatic tracheopharyngeal fistula caused by foreign body impaction. A conservative, endoscopic treatment strategy with broad-spectrum antibiotics, transnasal drainage, and covered tracheal stent placement was used. The stent was removed after 4 weeks, and complete closure of the fistula tract was confirmed by endoscopy and contrast esophagram. Although tracheopharyngeal fistulae are rare and operative treatment can be complex, this case demonstrates that conservative management with antibiotics, drainage, and endoscopic stenting can be successful in select patients.

Repair of post-intubation tracheoesophageal fistulae through the left pre-sternocleidomastoid approach: a recent case series of 13 patients

OBJECTIVE

Post-intubation tracheoesophageal fistula (TEF) is a late complication of tracheotomy, while membranous trachea laceration during percutaneous dilational tracheostomy is implicated in the generation of early post-tracheotomy TEF. Surgical repair is the only viable option for these patients and the technique of repair depends on a variety of factors.

METHODS

Totally 13 patients (mean age: 54.1±12.6 years; male: 8) with post-intubation TEF were managed between 2007 and 2013. The diagnosis was always made through esophagoscopy followed by endoscopic gastrostomy and bronchoscopy for repositioning of the tracheal tube just above the carina. Repair of the fistula was made in all patients through a left pre-sternocleidomastoid incision followed by dissection of the fistulous tract, suturing of esophagus and trachea and interposition of the whole pedicled left sternocleidomastoid muscle (SCMM) between the two suture lines.

RESULTS

Five out of the 13 procedures were performed in mechanically ventilated patients; 3 of them died from septic complications during the postoperative period while fistula recurred in 1 of those 3 patients due to extensive inflammation of the tracheal wall. The rest 8 patients underwent fistula repair after weaning from mechanical ventilation and the results of repair were excellent. The additional procedure of temporary T-tube insertion was obviated in one patient to manage extensive tracheomalacia.

CONCLUSIONS

The left pre-sternocleidomastoid incision is an excellent access for the repair of a post-intubation TEF without tracheal resection. The interposition of the whole left pedicled SCMM between the suture lines of trachea and esophagus avoids fistula recurrence and offers the best chance for cure.

Treatment of esophageal leaks, fistulae, and perforations with temporary stents: evaluation of efficacy, adverse events, and factors associated with successful outcomes

BACKGROUND

Factors associated with successful endoscopic therapy with temporary stents for esophageal leaks, fistulae, and perforations (L/F/P) are not well known.

OBJECTIVES

To evaluate the safety, efficacy, and outcomes of esophageal stenting in these patients and identify factors associated with successful closure.

DESIGN

Retrospective.

SETTING

Academic tertiary referral center.

PATIENTS

All patients with attempted stent placement for esophageal L/F/P between January 2003 and May 2012.

INTERVENTION

Esophageal stent placement and removal.

MAIN OUTCOME MEASUREMENTS

Factors predictive of therapeutic success defined as complete closure after index stent removal (primary closure) or after further endoscopic stenting (secondary closure).

RESULTS

Sixty-seven patients with 132 attempted stents for esophageal L/F/P were considered; 13 patients were excluded. Among the remaining 54 patients, 117 stents were placed for leaks (29 patients; 64 stents), fistulae (15 patients; 36 stents), and perforations (10 patients; 17 stents). Procedural technical success was achieved in all patients (100%). Primary closure was successful in 40 patients (74%) and secondary closure in an additional 5 (83% overall). On short-term (<3 months) follow-up, 27 patients (50%) were asymptomatic, whereas 22 (41%) had technical adverse events, including stent migration in 15 patients (28%). Factors associated with successful primary closure include a shorter time between diagnosis of esophageal L/F/P and initial stent insertion (9.03 vs 22.54 days; P = .003), and a smaller luminal opening size (P = .002).

LIMITATIONS

Retrospective, single-center study.

CONCLUSIONS

Temporary stents are safe and effective in treating esophageal L/F/P. Defect opening size and time from diagnosis to stent placement appear to be candidate predictors for successful closure.

Review of (acquired) incidental, rare and difficult tracheoesophageal fistula management

Acquired benign tracheoesophageal fistula is a rare condition and a difficult problem. The rarity and unpredictable presentation of this condition makes the design and setting of randomized prospective trials impossible. Guidelines on this matter are also difficult to establish. Based on a comprehensive evaluation of published literature and their experience, the authors review the etiology and best options for treatment, either surgical and non surgical, according to present knowledge.

Evidence-based recommendations on upper gastrointestinal tract stenting: a report from the stent study group of the korean society of gastrointestinal endoscopy

Endoscopic stents have evolved dramatically over the past 20 years. With the introduction of uncovered self-expanding metal stents in the early 1990s, they are primarily used to palliate symptoms of malignant obstruction in patients with inoperable gastrointestinal (GI) cancer. At present, stents have emerged as an effective, safe, and less invasive alternative for the treatment of malignant GI obstruction. Clinical decisions about stent placement should be made based on the exact understanding of the patient's condition. These recommendations based on a critical review of the available data and expert consensus are made for the purpose of providing endoscopists with information about stent placement. These can be helpful for management of patients with inoperable cancer or various nonmalignant conditions in the upper GI tract.

Combined tracheoesophageal transection after blunt neck trauma

Survival following tracheoesophageal transection is uncommon. Establishing a secure airway has the highest priority in trauma management. Understanding the mechanism of the incident can be a useful adjunct in predicting the likelihood and severity of specific anatomical patterns of injuries. We discuss published literature on combined tracheoesophageal injuries after blunt neck trauma and their outcome. A search of MEDLINE for papers published regarding tracheoesophageal injury was made. The literature search identified 14 such articles referring to a total of 27 patients. Age ranged from 3-73 years. The mechanism of injury was secondary to a rope/wire in 33%, metal bar in 4% of cases and unspecified in 63%. All of the patients were managed surgically. A number of tissues were used to protect the anastomosis including pleural and sternocleidomastoid muscle flaps. There were no reported mortalities. Patients with combined tracheoesophageal injury after blunt neck trauma require acute management of airway along with concomitant occult injuries.

Surgical treatment of nonmalignant tracheoesophageal fistula: a thirty-five year experience

BACKGROUND

Acquired nonmalignant tracheoesophageal fistula in the adult patient develops in a variety of conditions. We have applied surgical closure with success for 35 years.

METHODS

From 1975 to 1991, 38 patients underwent surgical repair of a tracheoesophageal fistula. A retrospective study of 36 additional patients undergoing surgical repair from 1992 to 2010 was conducted.

RESULTS

The most common causes were postintubation injury (n=17, 47%), trauma (n=6, 17%), prior laryngectomy (n=6, 17%), and prior esophagectomy (n=4, 11%). Four patients presented after failing fistula control with an endoluminal stent. The tracheal defect was closed with resection and reconstruction (n=17, 41%), laryngotracheal resection (n=5, 12%), membranous tracheal repair (n=17, 41%), or repair over a tracheal T tube (n=2, 5%), while esophageal repair consisted of 2-layer closure (n=31, 78%), 1-layer closure (n=6, 15%), esophagostomy (n=1, 3%), end-to-end esophageal anastomosis (n=1, 3%), or full thickness skin graft reconstruction (n=1, 3%). The esophageal and tracheal repairs were buttressed by interposing pedicled muscle or omental flaps in all patients. There was 1 postoperative death (3%). Recurrence after repair developed only in fistulas arising after esophagectomy or laryngectomy (n=4, 11%). Fistula closure was ultimately successful in 34 patients (94%). Twenty-nine patients (83%) resumed oral intake and 25 patients (71%) were breathing without a tracheal appliance.

CONCLUSIONS

Successful closure of benign tracheoesophageal fistula is achieved with several surgical techniques based on buttressed repair and restoration of normal breathing and swallowing. Closure of complex postsurgical fistula may fail. Endoluminal stenting was not found useful.

Benign esophagorespiratory fistula: a case series and a novel technique of definitive management

Benign esophagorespiratory fistula is a relatively rare condition in adults that poses a technical challenge to manage. This case series describes our experience in the treatment of benign esophagorespiratory fistula in 12 adults. A retrospective review of case records of 12 patients with benign esophagorespiratory fistula was done. There were eight tracheoesophageal fistulae and four bronchoesophageal fistulae. Among them, four fistulae were congenital, one was secondary to corrosive injury, three were due to foreign body (dentures), one was secondary to erosion because of prolonged endotracheal intubation, one was secondary to penetrating trauma, and two were infective in etiology. Of the 12 patients, there were nine males and three females. The mean age of presentation was 30.16 years (range 15-53 years). Nine patients had a definitive surgical intervention. The esophageal end of the fistula was managed by primary closure of the esophageal defect and reinforcement with pleural or intercostal muscle flap or a subtotal esophagectomy. The respiratory end of the fistula was dealt with by primary closure of the defect or by a novel technique of neomembranous airway formation, whereby the tracheal defect was closed with the help of a vascularized patch of the esophageal wall. The technique of this neomembranous airway formation is described in detail, and to our knowledge, this is the first time that this technique is being reported in the English literature. This technique is a novel method for definitive repair and can be considered as an option for repair of esophagorespiratory fistula with large defects.

Successful closure of intractable tracheoesophageal fistula using a combination of a modified silicon stent and metallic stents

Although surgery is the usual management strategy for acquired benign tracheoesophageal fistula, sometimes this approach is contraindicated or the patient declines surgical management. In this report, we describe a case of a patient with tracheoesophageal fistula at the level of the carina due to bronchial arterial infusion chemotherapy. Closure could not be achieved in response to multiple treatment strategies, including airway stenting, esophageal stenting, occlusion with microcoils, or cyanoacrylate glue. We subsequently achieved closure of this fistula through the combination of a modified silicon stent and metallic stents.

[Surgical repair of postintubation esophago-tracheal fistulas: report of two cases surgically repaired]

Persistence of postintubation esophago-tracheal fistulas is a difficult therapeutic problem. Authors present and discuss two successfully operated cases. Surgical reconstruction was done via left lateral cervical approach, including dissection of the fistulous tract, closure of the defect on both sides by suture, exclusion of the esophagus with a linear stapler beyond a loop esophagostomy, separation the suture lines with interposing of omohioid muscle flap, and making a Pezzer-catheter splinted esophagostomy. In the first case the spontaneous recanalization of the occluded esophagus was prolonged and the fistula recurred. Reoperation was done by the same procedure without exclusion of the esophagus. The second patient needed intervention because of the prolonged closure of esophagostomy. Recovery of both patients was successful. In conclusion, it can be stated that adaptation of surgical techniques for the individual pathologic situation helped the authors to find the way to the successful outcome.

Management of acquired tracheoesophageal fistula with various clinical presentations

PURPOSE

To determine the best therapeutic approach for acquired tracheoesophageal fistulae in childhood by evaluation of distinct clinical presentations requiring different surgical management based on our clinical experience.

PATIENTS AND METHODS

Seven patients with acquired tracheoesophageal fistula seen between 1999 and 2010 were retrospectively studied with regard to the presenting findings, diagnostic evaluation, therapeutic approach, and outcomes.

RESULTS

Five girls and two boys with a median age of 36 months (range, 2-156 months) were treated for acquired tracheoesophageal fistula. The presenting symptoms were respiratory difficulty (n = 3), coughing (n = 2), and dysphagia with coughing (n = 2), with a median duration of 30 days (range, 1-730 days). The etiologies were disc battery ingestion (n = 3), placement of endoesophageal prosthesis for caustic esophageal stricture (n = 2), corrosive ingestion with extensive burn (n = 1), and blunt chest trauma with subsequent emergency tracheotomy (n = 1). The site of the fistulae were proximal (n = 3) and middle (n = 1) trachea, left main bronchus (n = 1), and nearly the entire posterior wall of the trachea (n = 2). The patients were variously managed: conservatively with eventual spontaneous closure (n = 1), primary repair (n = 2), and colon interposition after cervical esophagostomy (n = 4) based on the clinical evaluation on admission and the follow-up status. Stenosis of the proximal esophagus (n = 2) and esophagocolonic anastomosis (n = 2) were the only complications encountered after treatment and were successfully managed with dilatation.

CONCLUSIONS

The best therapeutic approach for acquired tracheoesophageal fistula can be determined with careful consideration of relevant parameters on admission, including medical history, presenting findings, etiology, and characteristics of the fistula, in addition to the clinical evaluation in the follow-up period. In general, conservative management should precede definitive surgical intervention both to allow for possible spontaneous closure and also to achieve optimal preoperative status. Primary repair or a staged surgical approach can be best selected by giving priority to the patient's airway security.

Expandable stents for benign esophageal disease

Partially covered self-expandable esophageal stents have been associated with unacceptable complications when used for benign esophageal disorders. With the introduction of removable or potentially removable fully covered stents and biodegradable stents, interest in using expandable stents for benign indications has been revived. Although expandable stents can offer a minimally invasive alternative to surgery, they can be associated with serious complications; hence, this approach should be considered in carefully selected patients, preferably on a protocol basis.

Role of esophageal stents in benign and malignant diseases

These recommendations provide an evidence-based approach to the role of esophageal stents in the management of benign and malignant diseases. These guidelines have been developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. The following guidelines are based on a critical review of the available scientific literature on the topic identified in Medline and PubMed (January 1992-December 2008) using search terms that included stents, self-expandable metal stents, self-expandable plastic stents, esophageal cancer, esophageal adenocarcinoma, esophageal squamous cell carcinoma, esophageal stricture, perforations, anastomotic leaks, tracheoesophageal fistula, and achalasia. These guidelines are intended for use by health-care providers and apply to adult, but not pediatric, patients. As with other practice guidelines, these guidelines are not intended to replace clinical judgment but rather to provide general guidelines applicable to the majority of patients. Clinicians need to integrate recommendations with their own clinical judgment, and with individual patient circumstances, values, and preferences. They are intended to be flexible, in contrast to standards of care, which are inflexible policies designed to be followed in every case. Specific recommendations are based on relevant published information. The quality of evidence and strength of recommendations have been assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, which is a system that has been adopted by multiple national and international societies. The GRADE system is based on a sequential assessment of quality of evidence, followed by assessment of the balance between benefits vs. downsides (harms, burden, and costs) and subsequent judgment regarding the strength of recommendation.

Early repair of acquired tracheoesophageal fistula

We report early direct repair of a cuff-related tracheoesophageal fistula in a 30-year-old alcoholic man with diabetic ketoacidosis who fell unconscious and was ventilated via an endotracheal tube. He was successfully weaned from the ventilator 1 week after the operation.