Management of Acquired Benign Tracheoesophageal Fistulae

Airway Esophageal Fistula

Acquired tracheoesophageal fistulas (TEFs) are rare pathologic connections between the trachea and esophagus. Esophageal and tracheal stenting have been increasingly and safely utilized in management of TEFs, but surgical repair remains the most definitive treatment. Surgical approach to treating TEFs depends on its location, but principles include division and closure of the fistula tracts and insertion of a muscle flap in between the repairs to buttress and prevent recurrence. Advances in diagnostic tools, endoscopic and surgical methods, and intensive care have led to significantly improved outcomes in the management of acquired TEFs.

Acquired tracheoesophageal fistula repaired with one-stage surgery without tracheal resection using lateral cervical approach, a case report

INTRODUCTION

Acquired non-malignant tracheoesophageal fistula (TEF) is a rare pathological connection between the trachea and esophagus caused primarily by iatrogenic injuries. Cuff-related injury causes pressure necrosis of the tracheoesophageal walls, often due to the overinflation of tubes.

PRESENTATION OF CASE

A 29-year-old male who was mechanically ventilated for 3 months developed TEF after weaning from ventilation. The patient had severe sepsis, right lower lobe pneumonia, and parapneumonic effusion requiring multidisciplinary approach management. Preoperative measures were applied, including control of sepsis, nutritional support, stomach decompression, lung physiotherapy, placement of the cuff distal to the fistula, and weaning from ventilation. We performed a one-stage TEF repair with an interposition strap muscle flap using the lateral approach.

DISCUSSION

The surgical approach greatly depends on the fistula location, size, and concomitant tracheal stenosis. Large TEFs or tracheal stenosis are repaired with segmental tracheal resection and anastomosis. Small TEFs and a normal trachea are repaired with direct closure of tracheal and esophageal defects, which can be performed through lateral or anterior cervicotomy.

CONCLUSION

This case emphasizes the importance of a multidisciplinary approach, preoperative management, and meticulous surgical technique in the management of acquired TEF.

Establishment of acquired tracheoesophageal fistula using a modified magnetic compression technique in rabbits and its postmodeling evaluation

BACKGROUND

Previous studies have validated the efficacy of both magnetic compression and surgical techniques in creating rabbit tracheoesophageal fistula (TEF) models. Magnetic compression achieves a 100% success rate but requires more time, while surgery, though less frequently successful, offers rapid model establishment and technical maturity in larger animal models.

AIM

To determine the optimal approach for rabbit disease modeling and refine the process.

METHODS

TEF models were created in 12 rabbits using both the modified magnetic compression technique and surgery. Comparisons of the time to model establishment, success rate, food and water intake, weight changes, activity levels, bronchoscopy findings, white blood cell counts, and biopsies were performed. In response to the failures encountered during modified magnetic compression modeling, we increased the sample size to 15 rabbit models and assessed the repeatability and stability of the models, comparing them with the original magnetic compression technique.

RESULTS

The modified magnetic compression technique achieved a 66.7% success rate, whereas the success rate of the surgery technique was 33.3%. Surviving surgical rabbits might not meet subsequent experimental requirements due to TEF-related inflammation. In the modified magnetic compression group, one rabbit died, possibly due to magnet corrosion, and another died from tracheal magnet obstruction. Similar events occurred during the second round of modified magnetic compression modeling, with one rabbit possibly succumbing to aggravated lung infection. The operation time of the first round of modified magnetic compression was 3.2 ± 0.6 min, which was significantly reduced to 2.1 ± 0.4 min in the second round, compared to both the first round and that of the original technique.

CONCLUSION

The modified magnetic compression technique exhibits lower stress responses, a simple procedure, a high success rate, and lower modeling costs, making it a more appropriate choice for constructing TEF models in rabbits.

MSCT study for adult esophageal diverticulum with secondary broncho-esophageal fistula

BACKGROUND

Broncho-esophageal fistula (BEF) secondary to esophageal diverticulum is a rare clinical condition, which is often misdiagnosed for a long time. The aim of our study is to summarize and clarify the advantages of MSCT in diagnosing BEF secondary to esophageal diverticulum.

METHODS

We retrospectively analyzed patients clinically diagnosed with BEF from January 2005 to January 2022 at Jilin University First Hospital. Only those patients with BEF secondary to esophageal diverticulum and complete clinical data met our enrolled standard. All patients' clinicopathologic characteristics and MSCT features were systemically evaluated.

RESULTS

17 patients were eligible for our cohort study, including male 10 and female 7. The patient's mean age was 42.3 ± 12.5. The chronic cough occurred in all seventeen patients and bucking following oral fluid intake was documented in nine patients. MSCT distinctly suggested the fistulous tract between the bronchi and the esophagus in all patients. The mean diameter of the orifices in the wall of the esophagus was 4.40 ± 1.81 mm. The orifice in the midthoracic esophagus side was 15 cases and 2 cases at the lower thoracic esophagus. The involved bronchus included 13 cases at the right lower lobe bronchus, 1 at the right middle lobe bronchus and 3 at the left lower lobe bronchus. The contrast agent was observed in the pulmonary parenchyma in 10 of 13 patients who underwent esophagogram. No definite fistula was observed in 3 of 11 who underwent gastroscopy, while the intra-operative findings supported the existence of fistula.

CONCLUSIONS

BEF secondary to esophageal diverticulum tends to occur between the midthoracic esophagus and the right lower lobe bronchus. Compared with esophagography and gastroscopy, MSCT shows more comprehensive information about the fistulous shape, size, course and lung involvement, which are helpful for establishing diagnosis and guiding subsequent treatment.

Post-Intubation Tracheoesophageal Fistula: Surgical Management by Complete Cervical Tracheal Transection

We report successful surgical management of post-intubation tracheoesophageal fistula (TEF) in an adult patient requiring long-term mechanical ventilation. A complete tracheal transection without tracheal resection, via an anterior cervical approach, followed by direct closure of tracheal and esophageal defect, and interposition of muscle flap between the suture lines and tracheal reconstruction was performed. In selected cases, this surgical procedure may be a viable alternative to traditional techniques used to treat post-intubation TEF via the anterior or lateral cervical approach.

Coin Aspiration Presenting as Chronic Cough and Tracheoesophageal Fistula

Chronic cough can be a diagnostic challenge in the pediatric population. Foreign body aspiration without typical signs and symptoms can often be overlooked as a cause of chronic cough in children. Coin aspirations in the trachea typically have a sagittal orientation on an anteroposterior (AP) chest radiograph. We report a rare case of a previously healthy five-year-old girl presenting with a chronic cough for five months caused by a coin with a coronal orientation on an AP chest radiograph. The coin, initially presumed to be lodged in the esophagus, was actually lodged in the cervical trachea, leading to the development of a tracheoesophageal fistula (TEF). Her AP chest radiograph showed a coronal, circular radio-opaque shadow and the lateral view a tangential radio-opaque shadow, prompting an initial evaluation by esophagogastroduodenoscopy, which was normal. She then underwent rigid bronchoscopy, revealing a coin lodged in the trachea along with a TEF. Surgical removal was achieved through an external approach with a vertical tracheotomy and insertion of a tracheostomy tube. Five days later, a repeat rigid bronchoscopy showed a well-healed TEF, and she was successfully decannulated. She was ultimately discharged home on room air and oral feeds. TEF as a complication of a foreign body lodged in the trachea or esophagus is rare but life-threatening. Foreign body aspiration should always be considered in the differential diagnosis when evaluating younger children with chronic cough.

First-time use of a porcine small intestine submucosal plug device to close an acquired tracheo-esophageal fistula

BACKGROUND

Acquired tracheo-esophageal fistula (TEF) is a rare, life-threatening pathology, responsible for severe comorbidities. Its management is a real therapeutic challenge and remains controversial.

CASE PRESENTATION

We report the first case of endoscopic treatment of TEF by using a porcine small intestine submucosal (SIS) plug device in a young quadriplegic patient after failed surgical closure by cervicotomy. After 1 year of follow-up, oral feeding of the patient was resumed and no clinical signs of fistula recurrence were evident.

CONCLUSION

To our knowledge, we obtained for the first time, a satisfactory result for TEF closure with the use of a porcine SIS plug.

An Innovative Single Staged Surgical Repair of Benign Tracheoesophageal Fistula - A Case Report

Tracheo-oesophageal fistula (TOF) is defined as a pathological connection between the trachea and the oesophagus, leading to a spillover of oral and gastric secretions into the respiratory tract causing aspiration. The cause of TOF may be congenital or acquired. In this case report, a 48 years old female with acquired TOF, has been reported. The patient was on ventilator support for COVID-associated pneumonia and its complication with endotracheal tube for 3 weeks and then tracheostomy was done. Post recovery after weaning from the ventilator, the patient was diagnosed with TOF by bronchoscopy and confirmed by CT and MRI. Surgical closure was performed: the oesophageal defect was sutured in 2 layers and Tracheal wall was isolated and a pedicled strap muscle flap sutured into the defect between the trachea and esophagus. The etiology of TOF may be due to traumatic intubation, cuff pressure, or inflammation. A better knowledge about the cause, site, and size of the TOF will help in prompt surgical procedure and recovery of the patient. This single staged surgical closure can be safely performed in the majority of patients with acquired TOF for optimal outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03382-w.

Case report: Endoscopic closure with double stenting and autologous fascia lata graft of large tracheo-esophageal fistula

Introduction

Radiotherapy and esophageal stenting are usually employed to manage esophageal localization of distant cancer. However, they are also related to the occurrence of an increased risk of tracheoesophageal fistula. Tracheoesophageal fistula management in these patients involves dealing with poor general conditions and short-term prognosis. This paper presents the first case in literature of bronchoscopic fistula closure through an autologous fascia lata graft placement between two stents.

Case report and aim

A 67-years-old male patient was diagnosed with pulmonary squamous cell carcinoma in the inferior lobe of the left lung with mediastinal lymph node metastasis. After a multidisciplinary discussion, bronchoscopic repair of tracheoesophageal fistula with autologous fascia lata was decided without the removal of the esophageal stent due to the high risk on the esophagus possibly related to such a procedure. Oral feeding was progressively introduced without the development of aspiration symptoms. Videofluoroscopy and esophagogastroduodenoscopy were performed at 7 months showing no signs of tracheoesophageal fistula patency.

Conclusion

This technique might represent a low risks viable option for patients unsuitable for open surgical approaches.

Management of stent-related tracheoesophageal fistula in complex post-tuberculosis tracheobronchial stenosis: A case report

Background

The covered self-expandable metallic stents (SEMS) have been used to manage benign tracheobronchial stenosis, especially the complex post-tuberculosis (TB) tracheobronchial stenosis (PTTS) with cartilage destruction or malacia. This procedure could lead to stent-related tracheoesophageal fistula (TEF).

Case presentation

A 21-year-old woman, who had one covered Y-shaped SEMS inserted to manage complex PTTS 2 years ago, presented with dyspnea and frequent coughing on drinking water. The bronchoscopy confirmed extensive granulation tissue hyperplasia and a TEF on the upper edge of the covered SEMS. The covered SEMS was removed in three steps, and another fully covered Y-shape SEMS (Microtech Co., Ltd., Nanjing, China) was inserted to restore patency in the tracheobronchial tree and occlude the TEF orifice. Recombinant bovine basic fibroblast growth factor (rbFGF) (6,000 IU/time) was sprayed into and around the fistula through the V-System single-use cannula via the flexible bronchoscope every other week. The patient showed sustained clinical and radiographic improvement, and the TEF healed.

Conclusion

We presented a three-step bronchoscopic approach to managing a stent-related TEF in a patient with complex PTTS. Subsequently, regular bronchoscopic debridement of granulation tissue developing on the upper edge of SEMS is necessary to maintain the stent patency and reduce the risk of recurrent stent-related TEF. A fully covered SEMS associated with the local administration of rbFGF seems to offer an alternative simplified one-stage procedure for the temporary management of TEF combined with complex PTTS in non-surgical candidates.

Tracheoesophageal fistulas in coronavirus disease 2019 pandemic: A case report

BACKGROUND

Tracheoesophageal fistulas (TEFs) can be described as a pathological communication between the trachea and the esophagus. According to their origin, they may be classified as benign or malignant. Benign TEFs occur mostly as a consequence of prolonged mechanical ventilation, particularly among patients exposed to endotracheal cuff overinflation. During the severe acute respiratory syndrome coronavirus 2 virus pandemic, the amount of patients requiring prolonged ventilation rose, which in turn increased the incidence of TEFs.

CASE SUMMARY

We report the cases of 14 patients with different comorbidities such as being overweight, or having been diagnosed with diabetes mellitus or systemic hypertension. The most common symptoms on arrival were dyspnea and cough. In all cases, the diagnosis of TEFs was made through upper endoscopy. Depending on the location and size of each fistula, either endoscopic or surgical treatment was provided. Eight patients were treated endoscopically. Successful closure of the defect was achieved through over the scope clips in two patients, while three of them required endoscopic metal stenting. A hemoclip was used to successfully treat one patient, and it was used temporarily for another patient pended surgery. Surgical treatment was performed in patients with failed endoscopic management, leading to successful defect correction. Two patients died before receiving corrective treatment and four died later on in their clinical course due to infectious complications.

CONCLUSION

The incidence of TEFs increased during the coronavirus disease 2019 pandemic (from 0.5% to 1.5%). We believe that endoscopic treatment should be considered as an option for this group of patients, since evidence reported in the literature is still a growing area. Therefore, we propose an algorithm to lead intervention in patients presenting with TEFs due to prolonged intubation.

Evaluating the management timeline of tracheoesophageal fistulas secondary to button batteries: A systematic review

INTRODUCTION

During the SARS-CoV-2 pandemic, the incidence of pediatric button battery (BB) ingestions has risen. Children have spent more time at home from school, while many parents try to balance working from home and childcare. Additionally, the amount of electronics powered by BB has increased. Tracheoesophageal fistula (TEF) secondary to a retained aerodigestive BB is a devastating development. Management is challenging, and the clinical timeline of watchful waiting versus surgical intervention for TEF is poorly defined in the literature.

METHODS

In accordance with PRISMA guidelines, databases searched include PubMed, Scopus, and CINAHL from database date of inception through August 13, 2021. All study designs were included, and no language, publication date, or other restrictions were applied. Case series and reports of TEFs secondary to BBs were included. Clinical risk factors and outcomes were compared between the spontaneous closure and surgical repair groups.

RESULTS

A total of 79 studies with 105 total patients were included. Mortality was 11.4%. There were 23 (21.9%) TEFs that spontaneously closed and 71 (67.6%) that underwent surgical repair. Median time to spontaneous closure compared to surgical repair was significantly different (8.0 weeks [IQR 4.0-18.4] vs. 2.0 weeks [IQR 0.1-3.3], p<0.001). Smaller TEFs were more likely to spontaneously close versus being surgically repaired (9.3 mm ± 3.5 vs. 14.9 mm ± 8.3, p=0.022). Duration of symptoms before BB discovery, BB size, time between BB removal and TEF discovery, and location of the TEF were not statistically different between the spontaneous closure and surgical repair groups.

CONCLUSION

A TEF secondary to BB ingestion is a potentially deadly complication. Timing of reported TEF spontaneous closure varies significantly. While smaller TEFs may be amenable to healing without surgical repair, no other significant factors were identified that may be associated with spontaneous closure. If clinical status permits, these data suggest a period of observation of at least 8 weeks prior to surgical intervention may be practical for many BB-induced TEFs.

Surgical management of benign cervical tracheoesophageal fistulas: A single-tertiary academic institution experience

PURPOSE

Despite improvements of diagnosis and management, acquired benign tracheoesophageal fistulas (AB-TEFs) remain a challenging clinical problem and a life-threating condition. In the present study, we reviewed the early results and the long-term outcomes after surgical treatment of cervical AB-TEFs treated in our institution during the last 9 years.

METHODS

This retrospective study included patients who underwent transcervical repair of benign cervical AB-TEFs. Patients were identified from a prospectively filled electronic database which included patients' demographics, medical history, disease presentation, prior treatments, operative report, morbidity and mortality, hospital stay, postoperative results and follow-up information.

RESULTS

A total of 13 patients affected by cervical AB-TEF were treated. Most of the patients (91%) in our series were treated with a lateral cervicotomic approach with interposition of either sternocleidomastoid muscle flap (72.7%) or pectoralis major myocutaneous flap (9.1%) or infrahyoid muscle flap (9.1%). The univariate analysis of showed that the etiology and surgical technique were significantly associated with immediate postoperative outcome. Esophageal diversion was removed in all patients but 3 due to their neurological status, which was the only significant factor related to post-operative oral-intake (p =0.016). We experienced 2 (18.2%) failures of the reconstruction, which occurred in patients previously treated with chemoradiation for head and neck malignancies. None of the remaining patients (72.8%) relapsed after a long-term follow-up restoring a normal oral diet was restored.

CONCLUSION

The lateral cervicotomic approach with sternocleidomastoid flap interposition showed its effectiveness and safety in the treatment of AB-TEFs in our single-institution experience.

Tracheoesophageal Fistula in a COVID-19 Ventilated Patient: A Challenging Therapeutic Decision

COVID-19 associated severe respiratory failure frequently requires admission to an intensive care unit, tracheal intubation, and mechanical ventilation. Among the risks of prolonged mechanical ventilation under these conditions, there is the development of tracheoesophageal fistula. We describe a case of a severe COVID-19 associated respiratory failure, who developed a tracheoesophageal fistula. We hypothesized that one of the mechanisms for tracheoesophageal fistula, along with other local and general risk factors, is the local infection due to the location of the virus itself in the tracheobronchial tree. The patient was managed successfully with surgical intervention. This case highlights the increased risk of this potentially life-threatening complication among the COVID-19 patient cohort and suggests a management strategy.

Management of tracheo-oesophageal fistula in adults

Tracheo-oesophageal fistula (TOF) is a pathological connection between the trachea and the oesophagus that is associated with various underlying conditions including malignancies, infections, inhalation injuries and traumatic damage. As the condition spans multiple organ systems with varying aetiologies and acuities, TOF poses unique diagnostic and management challenges to pulmonologists, gastroenterologists and thoracic surgeons alike. Although stents have been a cornerstone in the management of TOF, there exists a large gap in our understanding of their efficacy and precise methodology, making stenting procedure both art and science. TOFs relating to underlying oesophageal or tracheal malignancies require advanced understanding of the airway and digestive tract anatomy, dimensions of the fistula, stent characteristics and types, and the interplay between the oesophageal stent and the airway stent if dual stenting procedure is elected. In this review article, we review the most up-to-date data on risk factors, clinical manifestations, diagnostic approaches, management methods and prognosis. Consequently, this article serves to evaluate current therapeutic strategies and the future directions in the areas of 3D-printed stents, over-the-scope clipping systems, tissue matrices and atrial septal closure devices.

Clinical Comparison of Airway Stent Placement in Intervention Room and Operating Room

BACKGROUND

Airway stent placement is the effective regimen for central airway obstruction (CAO), while its application scenarios varied. This study aimed to make clinical comparison of airway stent placement in the intervention room and operating room.

METHODS

Patients underwent airway stent placement between 2014 and 2018 were included in this retrospective case-control study. Clinical performance of airway stent placement in intervention room and operating room were compared.

RESULTS

82 patients were included in this study, including 39 in the intervention room and 43 in the operating room. Patients treated in the intervention room had lower Charlson comorbidity index (CCI) (P=0.018) and received less Y-shaped stents (P<0.001). Better clinical response (P=0.026), more stents placed (P<0.001) and longer length of stent (P<0.001) were observed in operating room, while there was no significantly statistical difference of stent-related complications and post-stent survival rate between the two groups. Extracorporeal membrane oxygenation (ECMO) supported airway stent placement procedures were performed in the operating room, which provided definitive safety support for high-risk intervention.

CONCLUSIONS

Patients with CAO could benefit from the operating room scenario, and airway stent placement in the operating room is more suitable for patients with higher CCI scores and receiving more complicated procedures.

Direct and indirect CT imaging features of esophago-airway fistula in adults

Background

Esophago-airway fistula (EAF) is an abnormal connection between the esophagus and the trachea or a major bronchus. While contrast esophagography remains the primary radiographic tool for the diagnosis of EAF, computed tomography (CT) is often employed in its evaluation. A systematic analysis of CT findings of EAF in adults has not been previously published. The goal of our study is to determine the direct and indirect CT findings of EAF in adults.

Methods

We identified patients with EAF detected on CT at our institution between January 1, 2001 and December 31, 2019, with endoscopic or surgical confirmation. We collected patient clinicopathologic characteristics and assessed CTs for direct and indirect imaging features of EAF in these patients.

Results

Twenty-six patients (median age: 56 years; range, 25–79 years; F=13, 50% and M=13, 50%) with confirmed EAF were identified. Half of the patients had an underlying malignancy. On CT, a direct connection between the esophagus and the airway was identified in most cases (22/26; 85%). Common indirect CT findings of EAF included esophageal wall thickening (21/26, 81%), mediastinal fatty stranding (21/26, 81%), airway wall thickening (20/26, 77%), fluid or debris within the airways (17/26, 65%), and focal or diffuse esophageal dilation with air (17/26, 65%). Mediastinal fluid collections were infrequently seen (4/26, 15%), but findings of aspiration or other pneumonia were common (19/26, 73%).

Conclusions

CT plays an essential role in both the primary and secondary evaluation of adult EAF resulting from both malignant and benign etiologies. CT may be the first diagnostic exam to suggest and detect the presence of EAF and may precede clinical suspicion, and it can detect a subset of fistulas not demonstrated on esophagography. There are several direct and indirect imaging findings on CT that can help in the detection of EAF.

Successful Closure of a Benign Refractory Tracheoesophageal Fistula Using an Over-the-Scope Clip after Failed Esophageal Stent Placement and Surgical Management

Tracheoesophageal fistulas (TEFs) have traditionally been managed surgically, but the endoscopic approach is widely performed as a less invasive alternative. Different closure techniques have been proposed with inconsistent results. An over-the-scope clip (OTSC) appears to be a reasonable option, but long-term results have not been well defined. We report the long-term outcomes of a complex case of successful closure of a benign refractory TEF using an OTSC after failed surgical management and esophageal stent placement.

Single application of airway stents in thoracogastric-airway fistula: results and prognostic factors for its healing

BACKGROUND

Thoracogastric-airway fistula (TGAF) post-thoracic surgery is a rare and challenging complication for esophagectomy. The aim of this study was to explore the effectiveness of airway stenting for TGAF patients and find related factors coupled with healing of fistula.

METHODS

This is a retrospective study involving patients with TGAF who were treated with airway stentings. Based on different TGAF locations and sizes on chest computed tomography, covered metallic or silicon airway stents were implanted to cover orifices under interventional bronchoscopy. TGAF healing was defined as the primary outcome, and complete sealing of TGAF as the second outcome. The predictors for TGAF healing were analyzed in univariate and multivariate analysis.

RESULTS

A total of 58 TGAF patients were included, of whom 7 received straight covered metallic stents, 5 straight silicon stents, 3 L-shaped covered metallic stents, 21 large Y-shaped covered metallic stents, 17 large Y-shaped silicon stents, and 5 with Y-shaped covered metallic stents. Healing was achieved in 20 (34.5%) patients, and complete sealing in 45 (77.6%) patients. There were no significant differences in healing rate and complete sealing rate between patients receiving metallic stents and those with silicon stents. In univariate analysis, lacking a previous history of radiotherapy or chemotherapy, nonmalignant fistulas, small fistulas, and shorter postesophagectomy duration were found associated with a higher rate of TGAF healing. Only shorter postesophagectomy duration was associated with TGAF healing in multivariate analysis.

CONCLUSIONS

Both silicon and covered metallic airway stenting are effective methods to close TGAF. A shorter postesophagectomy period may predict better TGAF healing. The reviews of this paper are available via the supplemental material section.

Using a Miniature Stapler to Divide a Mucosal Bridge at the Anastomosis after Gastric Pull-up for Iatrogenic Tracheoesophageal Fistula

We report the first use of a miniature stapler to divide a mucosal bridge at the gastroesophageal junction after complex esophageal atresia (EA) repair. A 4-year-old girl was referred to our center after treatment of EA elsewhere. On our initial enodoscopy, a large iatrogenic tracheoesophageal fistula had formed, prompting us to perform a tracheoplasty and gastric interposition. One year after recovery, she had dysphagia with solid food. Upon endoscopy, a mucosal bridge was noted at the gastroesophageal anastomosis. This bridge was divided under endoscopy using a 5 mm miniature stapler. No complications were noted. Upon follow-up, she had no more complaints with solid food. Our report shows that the mucosal bridges may cause dysphagia after EA repair and can be safely divided using a miniature stapler.