Erosion of an Esophageal Endoprosthesis Into the Trachea

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.

Thoracic Esophageal Perforations

The authors review their experience with thoracic esophageal perforation at Inova Fairfax Hospital, June 1, 1988, to March 1, 2009. With the exception of 6 patients with occult perforation, all of whom survived with nonoperative therapy, aggressive surgical intervention was the standard approach. Among patients treated aggressively with surgery within 24 hours of perforation, hospital survival was 97 per cent versus 89 per cent for patients treated aggressively surgically after 24 hours. In the absence of phlegmon, implacable obstruction, or delay, primary repair resulted in 100 per cent survival. Where phlegmon or resolute obstruction existed, resection and reconstruction resulted in 96 per cent survival. Even when patients were deemed too ill to undergo surgery, cervical diversion was 100 per cent effective in eradicating continuing leak and achieved 89 per cent survival. Endoesophageal stenting was applied as primary treatment or secondarily such as where leak complicated primary repair. When stenting was used as the initial and primary treatment modality, survival was 88 per cent. Targeted drainage was helpful on occasion as an adjunct to initial therapies. Comfort measures alone were appropriate when clinical circumstances merited no effort at resuscitation. Finally, survivors were asked to self-categorize their ability to swallow; 95 per cent responded good to excellent.

Acquired tracheoesophageal fistula following disc-battery ingestion: can we watch and wait?

Acquired tracheoesophageal fistulas (TEF) are rare but dangerous complications of disc-battery ingestion. Management approaches include endoscopic or open surgical repair. Unfortunately, these procedures can be complicated by high rates of recurrent laryngeal nerve injury, tracheal stenosis, recurrent fistula and significant patient mortality. Thus, several authors have advocated the use of esophageal rest as conservative management of acquired TEF to permit closure by secondary intention. This study describes a patient with spontaneous closure of an acquired TEF following disc-battery ingestion. The late recurrence of the TEF following conservative management, and endoscopic and radiographic evidence of closure, illustrates the importance of long term evaluation before assuming fistula resolution. Practitioners must carefully weigh the risks and benefits before deciding surgical versus conservative management of TEF. An extended follow-up of at least 6 months should be instituted with a high index of suspicion if conservative management is utilized. Transtracheal repair using an imbricated suture technique is a good surgical option when conservative management fails.