The diagnosis and treatment of H-type tracheoesophageal fistula

Missed Proximal Tracheoesophageal Fistula (TEF) in a Neonate with Type D Esophageal Atresia

We present the case of a patient with the rare type D esophageal atresia (EA), diagnosed after correction of an EA initially diagnosed as type C. Routine postoperative contrast esophagogram showed a missed proximal tracheoesophageal fistula. This case report illustrates the potential difficulties to diagnose type D EA.

Outcome of Newborns with Tracheoesophageal Fistula: An Experience from a Rapidly Developing Country: Room for Improvement

Methods

This is a retrospective review of the medical electronic charts of patients with TEF that were followed at Sidra Medicine in the state of Qatar. The review included the patients who were operated upon in the period of 2011-2021 but continued to follow at our institution in the period of 2018-2021. Demographic data, associated anomalies, preoperative, operative, and postoperative courses, and growth parameters were collected.

Results

A total of 35 patients with TEF (24 males and 11 females) were collected. 49% were full term. We identified seven patients (20%) with isolated TEF, TEF with VACTERL association in 29% of our patients, other chromosomal anomalies in 17%, or associated with other anomalies (not related to VACTERL) in 34% of the patients. The majority of the patients (94%) were of type C-TEF (TEF with esophageal atresia-EA/TEF). All patients were operated except for one patient who died at 2 days of life due to cardiac complications. Median age at which surgery was performed was 2 days (range 1-270 days). Median follow-up was 32 months (range 7-115 months). Immediate postoperative complications were encountered in eleven patients (33%) and included anastomosis leak in 12%, air leak in 6%, sepsis in 6%, chylothorax in 3%, vocal cord palsy and fistula recurrence (combined) in 3%, and failure of TEF closure in 3% of the patients. Long-term respiratory complications were encountered in 43% of our patients. Long-term gastrointestinal complications included gastroesophageal reflux (GERD) in 63%, dysphagia in 31%, and anastomotic stricture in 34% of the patients. Growth was affected in around a quarter of the patients at 6 months after surgery and 22% at 12-month assessment postoperatively. While only five patients died at our institution, only one was directly related to failure of TEF closure and postoperative complications.

Conclusion

This descriptive study reports the clinical outcome of TEF from a rapidly developing country. The distribution of the patients' characteristics and postoperative complications was almost comparable to those from developed countries. This study would aid in addressing the prognostic factors and establishment of evidence-based management pathways of newborns with TEF to improve the clinical outcome in our center and other pediatric tertiary centers in developing countries.

A case of Gross E esophageal atresia discovered following a unique clinical course

The patient was a 15 months-old boy who had been diagnosed CHARGE syndrome, which is a multiple congenital anomaly syndrome caused by mutations in the CHD7 gene. Mechanical ventilation management was initiated 2 hours after birth for dysphagia and respiratory failure, and tracheotomy was performed 3 months after birth for dysphagia and failed extubation. He was repeatedly hospitalized due to pneuomoniae. Approximately 1 year after birth, the boy had two consecutive episodes of sudden ventilatory insufficiency while replacing the tracheotomy cannula. A bronchoscopic examination under general anesthesia revealed a tracheoesophageal fistula directly below the tracheostomy. The patient was diagnosed with Gross E esophageal atresia, and we speculated that the cannula migrated to the esophagus via the fistula during tracheostomy cannula replacement. Gross E esophageal atresia is a rare disease. Its diagnosis is often delayed, and it is discovered by recurrent pneumonia in many cases. A tracheoesophageal fistula may also be found in children with deformities of the respiratory system. Furthermore, tracheoesophageal fistulae are often found in the neck. Therefore, when sudden ventilatory insufficiency occurs in a child with a tracheostomy after replacing the tracheostomy cannula, caution must be exercised since the cannula may have migrated to the esophagus via a fistula. J. Med. Invest. 69 : 141-144, February, 2022.

Low flow intermittent bronchoscopic oxygen insufflation to identify occult tracheo-esophageal fistulas

BACKGROUND

Esophageal atresia and tracheo-esophageal fistula (TEF), a well described congenital anomaly of the aero-digestive tract, commonly presents with inability to swallow and feed immediately after birth. However, diagnosis of recurrent or isolated TEF can be challenging and requires a combination of endoscopic and contrast studies. We describe a hitherto unreported technique of low flow intermittent oxygen insufflation into the suspicious tract and examine its safety and diagnostic yield for identification of occult TEF.

METHODS

A retrospective single center cohort study, analyzing case notes of patients with TEF who underwent bronchoscopic oxygen insufflation for suspected recurrent or isolated TEF between 2006 and 2019 at a tertiary pediatric hospital.

RESULTS

One-hundred and seven patients with TEF underwent 142 bronchoscopies during the study period. Of these, 22 patients underwent 28 bronchoscopies with oxygen insufflation. Twelve (43%) open fistulas were identified; of these, 9 (75%) were found using oxygen insufflation, revealing the fistula in 4/9 (44%) cases that had not been apparent using simple bronchoscopic visualization alone. One fistula was missed with multiple investigations, including bronchography and found only using oxygen insufflation. No complications were encountered.

CONCLUSIONS

Recurrent or isolated TEF may be missed using ordinary flexible bronchoscopy and imaging studies. Low flow oxygen insufflation can be applied safely and may detect otherwise occult TEF.

Congenital and acquired tracheoesophageal fistulas in children

Tracheoesophageal fistulas (TEF) are an anomalous communication between airway and esophagus. There are several types of TEF. Congenital are mainly associated to an esophageal atresia. The type III or C, in which the upper segment of the esophagus ends in a blind pouch and there is distal tracheoesophageal fistula above the carina, accounts for 85% of esophageal atresias. The other are extremely infrequent. H-type or N-type TEF, classified as type 5 or E, is an uncommon variant and accounts for less than 4%. Recurrent TEF is a serious complication after first surgery of esophageal atresia and TEF. The rate of recurrence of TEF is estimated between 3-15%. The treatment is a challenge with a high rate of recurrence after surgery. Classical symptoms of RTEF include coughing especially after drinking, abdominal distension, repeated cyanosis, and respiratory infections. In the case of H-type fistula the symptoms are similar but appear during the first month of life. In this chapter we presented the management and alternative treatments of the congenital and acquired TEF.

Rare Diseases of Larynx, Trachea and Thyroid

This review article covers data on rare diseases of the larynx, the trachea and the thyroid. In particular, congenital malformations, rare manifestations of inflammatory laryngeal disorders, benign and malignant epithelial as well as non-epithelial tumors, laryngeal and tracheal manifestations of general diseases and, finally, thyroid disorders are discussed. The individual chapters contain an overview of the data situation in the literature, the clinical appearance of each disorder, important key points for diagnosis and therapy and a statement on the prognosis of the disease. Finally, the authors indicate on study registers and self-help groups.

Care recommendations for the respiratory complications of esophageal atresia-tracheoesophageal fistula

Tracheoesophageal fistula (TEF) with esophageal atresia (EA) is a common congenital anomaly that is associated with significant respiratory morbidity throughout life. The objective of this document is to provide a framework for the diagnosis and management of the respiratory complications that are associated with the condition. As there are no randomized controlled studies on the subject, a group of experts used a modification of the Rand Appropriateness Method to describe the various aspects of the condition in terms of their relative importance, and to rate the available diagnostic methods and therapeutic interventions on the basis of their appropriateness and necessity. Specific recommendations were formulated and reported as Level A, B, and C based on whether they were based on "strong", "moderate" or "weak" agreement. The tracheomalacia that exists in the site of the fistula was considered the main abnormality that predisposes to all other respiratory complications due to airway collapse and impaired clearance of secretions. Aspiration due to impaired airway protection reflexes is the main underlying contributing mechanism. Flexible bronchoscopy is the main diagnostic modality, aided by imaging modalities, especially CT scans of the chest. Noninvasive positive airway pressure support, surgical techniques such as tracheopexy and rarely tracheostomy are required for the management of severe tracheomalacia. Regular long-term follow-up by a multidisciplinary team was considered imperative. Specific templates outlining the elements of the clinical respiratory evaluation according to the patients' age were also developed.

Surgical management of critical congenital malformations in the delivery room

Newborn emergencies that occur in the delivery room are frequently the result of life-threatening congenital anomalies that can result in death or severe disability if not treated in the immediate postnatal period. Prompt recognition and treatment of such disorders are paramount to ensuring the wellbeing of the infant. As congenital anomalies are frequently being diagnosed earlier due to improved prenatal detection, the coordination of planned interventions for life-threatening malformations is also becoming more common. This article serves as a guide for the presentation and initial management of the most common non-cardiac, newborn surgical emergencies.

Anesthesia Practice: Review of Perioperative Management of H-Type Tracheoesophageal Fistula

Tracheoesophageal fistula (TEF) is a rare congenital developmental anomaly, affecting 1 in 2500-3000 live births. The H-type TEF, consisting of a fistula between the trachea and a patent esophagus, is one of the rare anatomic subtypes, accounting for 4% of all TEFs. The presentation and perioperative management of neonates with H-type TEFs and all other TEFs are very similar to each other. Patients present with congenital heart disease and other defects and are prone to recurrent aspirations. A barium esophagogram or computed tomography of the chest is a common means to the diagnosis, and surgical repair is carried out through either a cervical approach or a right thoracotomy. During operation, anesthetic management is focused on preventing positive pressure ventilation through the fistula in an attempt to minimize gastric distension. For patients with H-type TEFs, because of the patent esophagus, symptoms are often less severe and nonspecific, resulting in subtle yet important differences in their diagnostic workup and management. This review will cover the finer details in the diagnosis and perioperative anesthetic management of TEF patients and clarify how H-type TEF distinguishes itself from the other anatomic subtypes.

Neural monitoring during H-type tracheoesophageal fistula division: A way to decrease recurrent laryngeal nerve injury?

Isolated tracheoesophageal fistula (TEF) is a rare condition with a previously reported high incidence of vocal cord paresis. A technique using recurrent laryngeal nerve monitoring is described as a strategy to potentially minimize the risk of vocal cord dysfunction in this patient population.

Congenital H-type tracheoesophageal fistula: A multicenter review of outcomes in a rare disease

OBJECTIVE

To perform a multicenter review of outcomes in patients with H-type tracheoesophageal fistula (TEF) in order to better understand the incidence and causes of post-operative complications.

BACKGROUND

H-type TEF without esophageal atresia (EA) is a rare anomaly with a fundamentally different management algorithm than the more common types of EA/TEF. Outcomes after surgical treatment of H-type TEF are largely unknown, but many authoritative textbooks describe a high incidence of respiratory complications.

METHODS

A multicenter retrospective review of all H-type TEF patients treated at 14 tertiary children's hospital from 2002-2012 was performed. Data were systematically collected concerning associated anomalies, operative techniques, hospital course, and short and long-term outcomes. Descriptive analyses were performed.

RESULTS

We identified 102 patients (median 9.5 per center, range 1-16) with H-type TEF. The overall survival was 97%. Most patients were repaired via the cervical approach (96%). The in-hospital complication rate, excluding vocal cord issues, was 16%; this included an 8% post-operative leak rate. Twenty-two percent failed initial extubation after repair. A total of 22% of the entire group had vocal cord abnormalities (paralysis or paresis) on laryngoscopy that were likely because of recurrent laryngeal nerve injury. Nine percent required a tracheostomy. Only 3% had a recurrent fistula, all of which were treated with reoperation.

CONCLUSIONS

There is a high rate of recurrent laryngeal nerve injury after H-type TEF repair. This underscores the need for meticulous surgical technique at the initial repair and suggests that early vocal cord evaluation should be performed for any post-operative respiratory difficulty. Routine evaluation of vocal cord function after H-type TEF repair should be considered.

THE LEVEL OF EVIDENCE RATING

Level IV.

Isolated tracheoesophageal fistula versus esophageal atresia - Early morbidity and short-term outcome. A single institution series

PURPOSE

We compared the postnatal course, morbidity and early results after repair for cases of isolated or "pure" TEF with those for cases of esophageal atresia (EA) with distal tracheoesophageal fistula (TEF).

METHODS

Twenty-four consecutive infants were divided into two groups: isolated TEF [TEF group] (n = 5) and EA with distal TEF [EA group] (n = 19).

RESULTS

A high rate of prematurity (29%) and major cardiac and other surgically-relevant malformations (0.8 vs. 0.7 per infant) was found in both groups. The median age at surgery was 8 days for the TEF group vs. 1 day for the EA group (p < 0.01). Most infants of both cohorts had stable acid-base and respiratory parameters at admission. Generally, tracheoscopy provided valuable information regarding the position of the TEF. Surgery for isolated TEF was performed via right cervicotomy in 4 cases and via thoracotomy in one. Postoperative thoracostomy tubes were inserted in 3 cases and one emergency gastrostomy was created for acute gastric overextension (exclusively in patients with EA). The duration of postoperative mechanical ventilation (49 vs. 113 h, p = 0.045) and the median length of stay in the pediatric surgery unit (10 vs. 20.5 days, p = 0.003) were shorter for the isolated TEF group. Four EA patients experienced severe events. Total mortality was 8% (0 out of 5 with TEF vs. 2 out of 19 with EA).

CONCLUSION

Developmental delay and a high rate of morbidity were found in both groups. More complex surgery increased perioperative morbidity in cases of EA. With early recognition of isolated TEF, a less complicated course can be expected in comparison with esophageal atresia.

Incidental diagnosis of an H-type tracheo-oesophageal fistula

A 6-day-old term neonate who was intubated on day 1 of life for apnoeic episodes, was transferred to the regional paediatric intensive care unit (PICU) for specialist opinion following 3 failed extubations in the neonatal unit. Escherichia coli congenital pneumonia was diagnosed and the child discharged to the local hospital. Chest radiographs and inflammatory markers were in keeping with infection. However, ongoing difficulties with secretions necessitated readmission to the PICU, following a significant cyanotic episode associated with coughing. On arrival at the PICU, a large leak around the endotracheal tube (ETT) was noted. On direct laryngoscopy, the ETT was found correctly positioned, through the cords, but air was noted to be coming back from the oesophagus. Advancing the ETT towards the carina terminated the leak and raised the suspicion of a tracheo-oesophageal fistula. An H-type tracheo-oesophageal fistula was confirmed on bronchoscopy. An uneventful fistula repair was performed and the baby discharged from the PICU on day 23 of life.

Congenital H-type tracheoesophageal fistula: a national multicenter study

BACKGROUND

Congenital H-type tracheoesophageal fistula (TEF) is very rare and represents <5 % of all congenital tracheoesophageal malformations. This is a national, multicenter review of our experience with isolated H-type TEF outlining clinical presentation, methods of diagnosis, associated anomalies, treatment and outcome

PATIENTS AND METHODS

The medical records of all patients with the diagnosis of congenital H-type TEF treated at four pediatric surgery units in Saudi Arabia were retrospectively reviewed for: age at diagnosis, sex, presenting symptoms, associated anomalies, method of diagnosis, treatment and outcome.

RESULTS

During the study period (January 1998-December 2013), 435 infants and children with the diagnosis of esophageal atresia with or without TEF were treated. Among these, 23 (5.3 %) had isolated TEF. There were 11 males and 12 females. Their age at presentation ranged from 5 days to 3 years and 7 months but the majority (90 %) were diagnosed during their first year of life. Their clinical presentation included: chocking and coughing during feeds in 12 (52.2 %), recurrent chest infection in 16 (69.6 %) and cyanosis in 10 (43.5 %). One presented with abdominal distension also. The diagnosis was made using esophagogram. In 11 (47.8 %), a single study confirmed the diagnosis, 8 (34.8 %) required two studies while 4 (17.4 %) required three studies. Nineteen (82.6 %) had preoperative bronchoscopy and in 13 (56.5 %), a catheter was used to cannulate the fistula. All were operated through a right cervical incision except one who underwent thoracoscopic ligation and division of the fistula. In one, the fistula was only transfixed and tied without being divided. This patient developed a recurrent fistula. Two patients developed postoperative stridor secondary to recurrent laryngeal nerve palsy. In both of them, there was complete recovery.

CONCLUSIONS

H-type TEF is very rare and commonly presents with recurrent chest infection, chocking and coughing during feeds and cyanosis. Physicians caring for these patients should be aware of this and a high index of suspicion is of paramount importance to avoid delay in diagnosis with its associated morbidity. A contrast esophagogram is valuable in confirming the diagnosis. The study however may need to be repeated. Preoperative bronchoscopy is valuable to localize and cannulate the fistula for easier access during surgery. Surgical repair is the treatment of choice and this should be performed through a right cervical incision or thoracotomy for low fistulae. Thoracoscopic ligation and division of a low H-type fistula is an alternative and less invasive approach when compared to thoracotomy.

Respiratory Care of Infants and Children with Congenital Tracheo-Oesophageal Fistula and Oesophageal Atresia

Despite acute respiratory and chronic respiratory and gastro-intestinal complications, most infants and children with a history of oesophageal atresia / trachea-oesophageal fistula [OA/TOF] can expect to live a fairly normal life. Close multidisciplinary medical and surgical follow-up can identify important co-morbidities whose treatment can improve symptoms and optimize pulmonary and nutritional outcomes. This article will discuss the aetiology, classification, diagnosis and treatment of congenital TOF, with an emphasis on post-surgical respiratory management, recognition of early and late onset complications, and long-term clinical outcomes.

Cervical/thoracotomic/thoracoscopic approaches for H-type congenital tracheo-esophageal fistula: a systematic review

PURPOSE

Aim of this systematic review is to investigate the thoracic and cervical surgical approaches of H-type tracheo-esophageal fistula (TEF) according to the position of the fistula.

METHODS

The PubMed database was searched for original studies on H-type TEF treatment published between 1977 and 2012. Manuscripts finally included were divided into open and thoracoscopic surgery groups.

RESULTS

Seventeen studies were selected for open surgery group, and most of them agree on the importance of pre-operative diagnosis of the fistula by preliminary tracheoscopy. Right cervicotomy was used in 70 cases (76.9%), left cervicotomy in 12 (13.2%), and thoracotomy only in 9 (9.9%). Five studies were included in thoracoscopic group (6 patients). Indications for the surgical approach (cervical vs thoracic) according to the position of the TEF were clearly described in 10 manuscripts, and all stated differences in surgical technique details. Complications and mortality rates were not statistically correlated to the different surgical approaches.

CONCLUSIONS

The evidence base in regard to the treatment of H-type fistula in children is poor and the skills and preferences of the surgeons guide the choice of the procedure. Surgical division of the fistula is curative, and the key to a successful repair is the pre-operatively identification of the level of the fistula with tracheoscopy. Right cervicotomy seems to be the approach of choice in the majority of case, with the thoracic approach appropriate only for fistulae opening below T2. Further well-designed prospective studies which take into account of selection and performance bias are strongly required.

Evaluating Necessity of Azygos Vein Ligation in Primary Repair of Esophageal Atresia

Surgery has dramatically improved survival of infants with esophageal atresia. However, early and late complications of these surgeries affect the future life of this population. A probable step toward minimizing such complications is through modifying the technique of surgery. We evaluated two groups of esophageal atresia undergoing surgery with two different techniques including preservation and ligation of the Azygos vein and compared early complications, duration of surgery, and hospital and neonatal intensive care unit (NICU) stay between them. A total number of 24 patients with mean age of 24 to 48 h, who were diagnosed with esophageal atresia, were included in the study. All cases were randomly allocated in two groups: group A (case group) in which patients underwent surgery with preservation of the Azygos vein and group B (control group) in which patients underwent the former surgical method with ligation of the Azygos vein. Incidence of early complications, duration of surgery, and NICU and hospital stay were compared between the two groups. None of the complications occurred in either group. Duration of surgery, NICU stay, and hospital stay were not statistically significant between the groups. Preserving the Azygos vein during esophageal atresia surgery is probably a good modification of the classic technique.

[Malformations of the esophagus: diagnosis and therapy]

Esophageal malformations are rare and can occur sporadically or as a component of various syndromes. The variations and classifications are manifold. With the available modern operation techniques most malformations can be resolved with good results. However, esophageal malformations are often combined with further malformations which limit the prognosis. The separation of the trachea and esophagus after gastrulation is not yet completely researched. The results so far indicate that the localized expression of various homeodomain transcription factors is essential for normal development of the trachea and esophagus.

[Isolated congenital tracheoesophageal fistula]

INTRODUCTION

Isolated tracheoesophageal fistula without esophageal atresia is a rare congenital malformation. Its etiology is obscure. Diagnosis is difficult but must be made early.

PURPOSE

To study the clinical, radiological, and evolutionary sights of this malformation.

PATIENTS AND METHODS

We report 4 cases of tracheoesophageal fistula, collected in the department of pediatric surgery of Monastir Hospital and in the neonatology unit of Sousse Hospital during the period between January 2001 and December 2010.

RESULTS

The clinical picture consisted in a coughing bout and cyanosis after each feeding. Thoracic and abdominal imaging showed aspiration pneumonia, atelectasis, and gas within the colon. Gastrointestinal opacification demonstrated the fistula in 2 cases. Tracheoscopy visualized the tracheoesophageal fistula in the other 2 cases. Treatment was surgical and consisted in the section-ligation of the tracheoesophageal fistula with pleural interposition in all cases. The course was simple in two cases with a 3-year and 3.5-year follow up, respectively, but the infants died in the other 2 cases.

CONCLUSION

Although a rare malformation, tracheoesophageal fistula should be suggested as a diagnosis when respiratory symptoms occur during feeding starting during the neonatal period.

Oesophageal atresia and tracheo-oesophageal fistula: current management strategies and complications

The successful operative management of oesophageal atresia and tracheo-oesophageal atresia has been available for approximately 70 years. During this time neonatal intensive care has evolved, surgical techniques have improved and consequently near 100% survival for this condition may now be achieved. In keeping with promising results, the co-morbidities of the condition have gained increasing recognition. In this article, the clinical course from antenatal assessments, neonatal surgery and co-morbidities from infancy to adulthood are reviewed to provide a broad overview of the condition.

An extremely rare abnormality of a double tracheoesophageal fistula without atresia of the esophagus; a case report and review of the literature

Tracheoesophageal fistulas without atresia of the esophagus are rare abnormalities of the upper gastrointestinal tract with an incidence rate of between 1% and 5%. Even more infrequent are 2 tracheoesophageal fistulas without atresia of the esophagus. This case report illustrates the history of an infant with 2 tracheoesophageal fistulas. The corresponding literature was reviewed, and a diagnostic algorithm was described.

H-type tracheoesophageal fistula in an extremely low birth weight premature neonate: appearance on magnetic resonance imaging

Many diagnostic methods have been used to establish the diagnosis for a suspected H-type tracheoesophageal fistula (TEF). In case of a strong assumption of an H-type fistula, besides all standard diagnostic work-up tools a more aggressive combined approach is advisable. However, in a critically ill premature infant, conventional invasive investigations could not be performed as being potentially hazardous and not always easy to achieve. We describe the unique imaging features of an H-type TEF on magnetic resonance imaging (MRI). Our case demonstrates that MR images could be used for diagnosis, and localization of an H-type TEF could be detected safely and accurately in a sick preterm infant.

Achalasia-like findings in a case with delayed diagnosis of H-type tracheoesophageal fistula

H-type tracheoesophageal fistula (TEF) may lead to chronic respiratory disease if the diagnosis is delayed. Long-standing fistula causes esophageal distention which is named as pneumoesophagus or megaesophagus and possibly affects the motility of the esophageal body which may also be encountered as a part of tracheoesophageal anomalies. Both dysmotility and megaesophagus may mimic achalasia radiologically and the patient may be advised an unnecessary esophagocardiomyotomy. The authors report a 15-year-old adolescent with H-type TEF who has been diagnosed during investigations for chronic respiratory disease due to presumptive diagnosis of achalasia. The authors emphasize that a complete anatomical and functional evaluation of the upper gastrointestinal tract should be done before recommending operation for achalasia in patients with chronic respiratory disease. H-type TEF should be investigated to avoid unnecessary cardiomyotomy.

Isolated tracheoesophageal fistula in a 10-year-old girl

Isolated tracheoesophageal fistula (H-TOF) is a rare type of tracheoesophageal anomaly and is in most cases diagnosed in the neonatal period because of choking and cyanosis during feeding. Diagnosis may be delayed even until adulthood because of nonspecific and sometimes intermittent symptoms, and because false-negative results of all diagnostic tools are not uncommon. We report a 10-year-old child with H-TOF, whose symptoms had nearly disappeared completely between the ages of 4 and 10 years. Diagnosis was only possible after the recurrence of the symptoms at the time of an episode of bronchitis, profound interrogation of the child's medical history, and questioning of the results of a former diagnostic work-up. In this article, we discuss the potential pitfalls in both clinical diagnosis and diagnostic work-up.

H-type congenital tracheoesophageal fistula: University Of Iowa experience 1985 to 2005

OBJECTIVES

We review the diagnostic workup, associated disorders, surgical technique, and postoperative course of patients who underwent repair of H-type tracheoesophageal fistulas.

METHODS

We performed a retrospective chart review of patients who received a diagnosis of tracheoesophageal fistula at the University of Iowa.

RESULTS

Seven patients with an H-type tracheoesophageal fistula and a single patient with a missed proximal fistula associated with esophageal atresia were identified. Their symptoms included coughing with feeding, recurrent pneumonia, and episodic cyanosis. A delay in diagnosis was seen in 4 patients and ranged from 2.5 months to 5.9 years. In all patients, the diagnosis was made with an esophagogram. The level of the fistulas was between C5 and T3, and all were successfully repaired via a right cervical approach.

CONCLUSIONS

A high index of suspicion for an H-type tracheoesophageal fistula should be maintained in the presence of neonatal respiratory symptoms, as the condition can be associated with a delay in diagnosis. Repeat esophagograms and bronchoscopy may be required for diagnosis. In the postoperative period, airway obstruction is a potential risk; however, long-term difficulty with swallowing, respiration, and phonation was not observed.

H-type tracheoesophageal fistula with type III laryngotracheoesophageal cleft

H-type tracheoesophageal fistula and laryngotracheoesophageal cleft are both rare anomalies. Laryngotracheoesophageal clefts are identified as a part of Opitz-Frias syndrome. We report a neonate with this combination of rare congenital anomalies. These associated malformations can have major implications in terms of resuscitation, diagnosis and surgical management, which are discussed.

Congenital anomalies of the esophagus

Normal anatomy, embryology, and congenital anomalies of the esophagus are discussed in this article. The classification, epidemiology, embryology, diagnosis, and management, including outcome following repair of esophageal atresia with or without an associated tracheoesophageal fistula, are described. The diagnosis and management of less common anomalies, such as congenital esophageal stenosis and congenital esophageal duplication, are outlined.

Tracheoesophageal fistula without esophageal atresia: are pull-back tube esophagograms needed for diagnosis?

BACKGROUND

A pull-back tube esophagogram (PBTE) is widely accepted in the literature as the radiological investigation of choice for the diagnosis of tracheoesophageal fistula without esophageal atresia. However, PBTE is rarely performed in our institution, as we have been successful in confirming the presence of such fistulae with a contrast material swallow (CS). We hypothesized that PBTE is not the radiological investigation of choice for the diagnosis of the fistula in this condition.

OBJECTIVE

We sought to determine what proportion of patients with tracheoesophageal fistula without esophageal atresia can be diagnosed promptly by a CS and what the indications are for a PBTE.

MATERIALS AND METHODS

We retrospectively analyzed the clinical and radiological findings in patients with tracheoesophageal fistula without esophageal atresia to determine whether the fistula was diagnosed with a CS or PBTE.

RESULTS

We identified 20 children (13 female and 7 male) with tracheoesophageal fistula without esophageal atresia. Their age at diagnosis ranged from 3 days to 168 months with a median of 9 days. The diagnosis was documented by CS in 12, PBTE in 7 and CT in 1. In three of the seven who had the fistula documented by PBTE, a previous CS had shown contrast material in the trachea, but no fistulous tract or aspiration was identified.

CONCLUSION

We believe that CS should be the examination of choice in most patients suspected of having a tracheoesophageal fistula without esophageal atresia. A PBTE is indicated in patients who are intubated or are at significant risk of aspiration. Furthermore, a PBTE is also indicated where contrast material is seen in the airway on CS and there is uncertainty whether this is due to aspiration or a fistula.

A Premature Infant With H-Type Tracheoesophageal Fistula Demonstrated by Scintigraphic Technique

PURPOSE

Congenital tracheoesophageal fistula (TEF) without esophageal atresia is commonly known as "H" type. This is extremely rare in infants. The rarity of the condition, its nonspecific symptomatology, and limitations in its demonstration by contrast radiology and endoscopy contribute to delays between first presentation and confirmation of the diagnosis. Our aim was to demonstrate a congenital H-type tracheoesophageal fistula by using Tc-99m sulfur colloid scintigraphy.

MATERIALS AND METHODS

A case report.

RESULTS

A preterm female infant was born by cesarean section at 34 weeks gestation. After many attempts of feeding, she developed apnea, resolving spontaneously, peroral cyanosis, pallor, hypersalivation, and abdominal distension, even when she was being fed by an orogastric tube. With this complex symptomatology, she was suspected to have an H-type TEF. Because of prematurity and recurrent respiratory problems of the infant and the high risk of aspiration of contrast material during a cineradiographic procedure, and also because of the invasive nature of the endoscopic procedure as well as the requirement of general anesthesia, the diagnosis was made by using Tc-99m sulfur colloid scintigraphy and confirmed at operation.

CONCLUSION

Demonstrating a congenital H-type tracheoesophageal fistula by using radionuclide imaging is an easily applicable technique.

Methylene blue for diagnosis of displaced atrial lines

Methylene blue (aniline violet, tetra-methylthionine chloride) has several important uses in clinical medicine, including diagnosis of displaced central lines. After cardiac surgery, three infants with suspected displacement of direct atrial lines were given methylene blue. After injection of the dye into the atrial lines, bluish discolouration was identified in their chest drainage. Use of methylene blue in small amounts appears to be a safe and effective way of diagnosing extravasation of fluid from displaced central lines.

H-type tracheoesophageal fistula masquerading as achalasia cardia in a 13-year-old child

H-type tracheoesophageal fistula is rare. Although symptoms are present from birth, its rarity and overlap of symptoms with other respiratory conditions makes diagnosis difficult and delayed. We report a case of H-type fistula in a 13-year-old girl that was detected incidentally during investigations for achalasia cardia.

Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula

Congenital esophageal atresia (EA) and/or tracheoesophageal fistula (TEF) are common congenital anomalies. Respiratory and GI complications occur frequently, and may persist lifelong. Late complications of EA/TEF include tracheomalacia, a recurrence of the TEF, esophageal stricture, and gastroesophageal reflux. These complications may lead to a brassy or honking-type cough, dysphagia, recurrent pneumonia, obstructive and restrictive ventilatory defects, and airway hyperreactivity. Aspiration should be excluded in children and adults with a history of EA/TEF who present with respiratory symptoms and/or recurrent lower respiratory infections, to prevent chronic pulmonary disease.

Thoracoscopic repair of H-type tracheoesophageal fistula in the newborn: a technical case report

H-type tracheoesophageal fistula (H-TEF) without esophageal atresia makes up 4% to 5% of esophageal congenital abnormalities. The authors present the thoracoscopic treatment of a 2.47-kg newborn boy with a fistula between the second and third thoracic vertebrae diagnosed by esophagography. Four trocars were used for fistula closure, and tracheal and esophageal suturing were accomplished without intraoperative incident. Five days after surgery, results of a barium swallow excluded anastomotic leaks. The chest tube was removed, and oral feeding was initiated.

Methemoglobinemia and hemolysis after enteral administration of methylene blue in a preterm infant: relevance for pediatric surgeons

A preterm infant had methaemoglobulinemia and hemolytic anemia after enteral administration of methylene blue. The dye was administered to exclude a tracheoesophageal fistula. Methylene blue is a noxious product, especially in neonates. It should be considered a potential cause of acquired methemoglobulinemia, even after enteral administration.

Use of methylene blue to identify the minor papilla or its orifice in patients with pancreas divisum

BACKGROUND

In some patients with pancreas divisum, minor papilla cannulation is difficult because of uncertain identification of the papilla or its orifice, even after pancreatic secretory stimulation with secretin or cholecystokinin agonist.

METHODS

Two techniques with methylene blue were used to identify the minor papilla and its orifice more clearly in a series of patients: spraying methylene blue over duodenal mucosa in the region suspected to contain the minor papilla with/without secretin or cholecystokinin agonist administration, and injection of contrast medium containing methylene blue into the ventral pancreatic duct by means of the major papilla in cases of incomplete pancreas divisum. Results were reviewed retrospectively.

RESULTS

From January 2001 to May 2002, minor papilla cannulation with conventional methods initially failed in 38 of 305 patients with pancreas divisum because of an inconspicuous minor papilla orifice. Methylene blue was used to identity the minor papilla orifice in 14 of 38 patients (spraying, 13; injection, 1). Minor papilla cannulation was successful in 12 of 14 (86%) patients (spraying 11, injection 1). Mild pancreatitis developed in 1 patient.

CONCLUSIONS

Methylene blue spraying or injection appears to be a helpful technique for identification of the inconspicuous minor papilla orifice in patients with pancreas divisum.

Precise localization of a recurrent tracheo-oesophageal fistula using retrograde guide wire placement

A 4-month-old-infant was presented with a presumptive diagnosis of a recurrent tracheo-oesophageal fistula. Preoperative bronchoscopy failed to reveal any defects on the tracheal lumen; however, combined oesophagoscopy and bronchoscopy successfully identified the tracheal orifice of the fistula, which facilitated surgical identification of the recurrent fistula and proper placement of the tracheal tube.

Intraoperative fibreoptic bronchoscopy during neonatal tracheo-oesophageal fistula ligation and oesophageal atresia repair

Maintenance of adequate ventilation under anaesthesia can be difficult during identification and ligation of congenital tracheo-oesophageal fistula with repair of oesophageal atresia. Anaesthesia may also be complicated by problems associated with prematurity, pre-existing aspiration pneumonitis, and difficulty positioning the endotracheal tube to prevent inflation of the stomach with increased risk of aspiration and diaphragmatic splinting. Even intubation of the fistula and gastric rupture may occur. Two neonatal cases are presented where use of a 2.2 mm neonatal bronchoscope passed through a 3.0 mm ID tracheal tube facilitated surgical identification of the fistula, diagnosis of fistula intubation and other airway problems intraoperatively.

Simplified access for division of the low cervical/high thoracic H-type tracheoesophageal fistula

H-type tracheoesophageal fistulas (H-TEF) often are located in the low cervical/high thoracic region where determination of the most appropriate surgical approach is difficult. When it can provide adequate exposure, a cervical incision is preferred because of the likelihood of decreased morbidity. A child with VACTERL association presented with recurrent respiratory problems. Esophagogram showed an H-TEF below the level of the clavicle. A vascular guide wire was placed through the H-TEF with the ends brought out through the mouth. Under fluoroscopic guidance, gentle traction was placed on the wire to bring the fistula into the neck for an easily accessible cervical exposure, thus eliminating the need for a thoracotomy.

Definitive localization of isolated tracheoesophageal fistula using bronchoscopy and esophagoscopy for guide wire placement

PURPOSE

To aid in identification of isolated tracheoesophageal fistulas (TEF), many surgeons have recommended the bronchoscopic placement of a ureteric or Fogarty catheter. This method can fail because of intraoperative dislodgment of the catheter. The authors present a new technique that enables us to definitively isolate and treat all H-type fistulas.

METHODS

Six cases of isolated TEF are presented consisting of 4 H-type fistulas, a proximal pouch fistula, and a recurrent TEF. Three of the patients had undergone a total of four prior failed operations at outside institutions using attempted bronchoscopic catheter placement. On all six patients, bronchoscopy was first performed where the fistula tract was noted in the trachea and a guide wire was passed through the fistula. After orotracheal intubation, the authors performed rigid esophagoscopy; the guide wire was identified and brought out through the mouth. This created a wire loop through the fistula. With the use of x-ray we were then able to visualize the level of the fistula and determine whether a cervical or thoracic approach should be used. Identification of the fistula intraoperatively was then facilitated by traction on the loop by the anesthesiologist.

RESULTS

Five of the six TEFs were repaired with neck exploration; one required right thoracotomy. In all patients, the fistula was identified and divided. There were no recurrences or other complications.

CONCLUSION

This new technique is a simple and definitive method in identification and treatment of isolated TEF.