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.

Internal mammary artery perforator flap for repair of an upper thoracic tracheo-oesophageal fistula

Tracheoesophageal fistulas (TOF) following esophagectomy for esophageal cancer are rare but potentially fatal. There is no consensus on treatment between stenting and surgical repair, although the latter is associated with better distant survival. In surgical repair, the interposition of a flap improves healing by providing well-vascularized tissue and reinforcing the repair zone. The flaps described are usually muscular and decaying. We present the case of a malnourished fifty-year-old man who underwent intrathoracic surgical repair of symptomatic recurrent TOF using a skin flap based on the perforators of the internal thoracic artery (IMAP). The perforator flap was completely de-epidermized and tunneled under the sternum by a proximal and limited resection of the 3rd costal cartilage and placed at the posterior aspect of the trachea, with the excess tissue rolled up on either side. At 9 months, the patient showed no recurrence and improved general condition. The de-epidermized IMAP tunneled under the sternum intrathoracically is a reliable alternative to the conventional muscle flaps described in TOF management and an attractive additional tool in the plastic surgeon's surgical arsenal.

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.

Large malignant tracheo-oesophageal fistula with lung abscesses

Tracheo-oesophageal fistula (TOF) can arise as a rare complication of malignancy (especially oesophageal or lung cancers) and pose difficult diagnostic and management dilemmas. We explore a challenging case of large malignant TOF below.

Diagnosis and Management of a Massive Eight-Centimeter Acquired Tracheoesophageal Fistula

Here, we present the case of a 61-year-old veteran Hispanic male with recurrent aspiration pneumonitis, aerophagia, tympanic abdominal bloating, and a positive Ono's sign; symptoms present were secondary to diagnosed tracheoesophageal fistulas (TEFs). TEFs are abnormal connections between the esophagus and the trachea. In adult cases, several risk factors have been identified for acquired cases, which include infection, trauma, and cancer. Diagnosis of TEF can be challenging and, in most cases, requires high suspicion. Currently, there are no established guidelines for diagnosing and managing TEF. Clinical assessment and various imaging techniques are essential in the diagnostic process. This article will discuss the etiology, clinical presentation, diagnostic approaches, and management options for acquired TEFs.

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.

Tracheo-oesophageal fistula in a case of organophosphate poisoning

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Tracheoesophageal Fistula: Airway Management and Temporization in a Community Hospital Setting

A tracheoesophageal fistula (TEF) is a rare anatomical abnormality that can present significant challenges for the anesthesia provider. TEFs, depending on location and size, can result in aspiration, hypoxia, and difficulty with ventilation in the intensive-care unit (ICU) and operating room (OR) settings. Though usually seen and most commonly described as a congenital abnormality, it can also be an acquired condition in adults. Early recognition and diagnosis of TEF are of paramount importance to avoid respiratory complications. The rapid isolation of the TEF is key to management and different methods can be used to temporize the clinical situation until definitive surgical or endoscopic procedures can be accomplished. We discuss methods of temporization of the clinical situation, especially in a community hospital setting with limited access to immediate and sophisticated treatment.

Management of Cervical Tracheo-Esophageal Fistula by Lateral Cervical Approach: Our Experience'

Acquired Tracheo-esophageal fistula (TEF) is a challenging and complicated condition. The laryngeal protection is lost in acquired TEF cases due to the established connection between the esophagus and the airways leading to aspiration, pneumonia, and acute respiratory distress syndrome. Malignancy contributes to about 80% of acquired TEF. Nonmalignant causes for TEF include prolonged ventilation, trauma (iatrogenic, penetrating, or blunt injury), foreign bodies, corrosive burns, and granulomatous infections. With the advancements in critical care, the incidence of TEF post-ventilation is on the rise in recent decades. We would like to share our experience managing ten cases of nonmalignant acquired cervical TEF by the lateral cervical approach at our institute. Apart from the isolated TEF cases, one patient with concomitant tracheal stenosis was repaired simultaneously with good postoperative results. TEF was identified in two cases following removal of T-tube and solid stent respectively and was repaired successfully with lateral cervical approach with strap muscle flap interposition.

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.

Bronchoesophageal fistula diagnosed on modified barium swallow, a unique presentation

Modified barium swallow (MBS) studies, performed in conjunction with speech pathologists, are routinely performed to assess for aspiration. The narrow field of view over the area of interest limits assessment of pathology in the thoracic esophagus and airways. We report a case of a 79-year-old female with bronchoesophageal fistula diagnosed incidentally after abnormal findings on an MBS initially performed to assess for aspiration.

Acquired Tracheoesophageal Fistulas: A Case Report and Review of Diagnostic and Management Challenges

Acquired, nonmalignant tracheoesophageal fistulas (TEFs) often occur in the setting of prolonged use of endotracheal or tracheostomy tubes due to trauma and erosion of the tracheal wall inflicted by tube cuffs or direct tracheal contact. In this report, we present a patient with a tracheostomy who presented with recurrent aspiration pneumonia and was found to have a large TEF that was difficult to treat. We also discuss the diagnostic and management challenges concerning TEFs. TEFs, especially if large, lead to recurrent aspiration pneumonia and can be challenging to manage. Definitive management of TEFs involves surgical repair; meanwhile, endoscopic or bronchoscopic stenting to bypass the fistula can be performed. The fistula location, size, and concurrent positive pressure ventilation make its treatment challenging in those with chronic ventilatory dependence. Early recognition and multidisciplinary management involving gastroenterologists, interventional pulmonologists, and thoracic surgeons are necessary to decide on the best treatment strategy.

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.

A unique approach for a large intra-thoracic traumatic tracheo-oesophageal fistula: A case report from Syria

Introduction and importance

Acquired tracheo-oesophageal fistula (TOF) is a rare complication of intubation or traumas, either blunt or penetrating. In a penetrating chest trauma, the closure of TOF can be challenging and requires a unique technique. A flap can and intra-tracheal tube can also be used. We present this case to demonstrate a unique late presentation of TOF and the unique approach that was used.

Case presentation

A patient presented with a large TOF caused by shrapnel, and was surgically managed after two months of the injury by using a smaller intra-tracheal tube, and using an oesophageal wall flap to close the tracheal defect and intercostal muscle flap was used for the oesophageal wall repair. The postoperative intrathoracic oesophageal leak was successfully treated conservatively.

Clinical discussion

Although the surgery could not be conducted until 2 months after the injury, the approach used was successful and the patient was able to resume his normal life after the surgery. The flap from the oesophagus and intercostal muscles and using a smaller tracheal tube successfully repaired the TOF with minimum stress on the suterings, and the conservative approach for the leak was also successful.

Conclusion

Traumatic TOF management can be complicated, but we speculate that using a smaller tube with the conservative management of the complications was ideal for the TOF acquired from a shrapnel.

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Acquired tracheo-oesophageal fistula (TOF) can be caused by trauma.

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The closure of TOF can be difficult and requires unique technique.

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Using a smaller intra- tracheal tube with a flap from oesophageal wall can help in TOF closure in the tracheas.

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Oesophagus wall injury from the shrapnel was managed by intercostal muscles.

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Post-operative oesophageal leak can be managed conservatively.

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.

A rare case of acquired benign tracheoesophageal fistula

Acquired benign tracheoesophageal fistula (TOF) is a rare medical condition that usually results from trauma, foreign bodies or granulomatous infections. This is an unusual presentation of a male patient with a history of laryngectomy who has had over a period of several years inappropriately and vigorously used valve cleaning brushes to clean tracheal secretions, which has led to the formation of a TOF. Due to the patient’s obsessive habit, we could not manage him using conventional surgical methods. Instead, we opted for the placement of a salivary bypass tube, which yielded good results and recovery. To the best of our knowledge, no other case of similar aetiology has been published. We would like to highlight the importance of appropriate patient selection and education prior to performing a tracheoesophageal puncture to avoid developing life-threatening complications as demonstrated in our case report.

Gastrointestinal CMV Disease and Tuberculosis in an AIDS Patient: Synergistic Interaction between Opportunistic Coinfections

The AIDS pandemic has made diseases such as tuberculosis, CMV disease, and other opportunistic infections more prevalent; these diseases may even be found to be associated among themselves, and the natural history of each disease may present in an unusual manner. We report the case of a 41-year-old man with HIV (CD4 of 144 cells/dL) and HCV with hematochezia due to tuberculosis in the ileocecal valve and descending colon and CMV tissue invasive disease in the esophagus and descending colon. Coinfection among tuberculosis and cytomegalovirus in the gastrointestinal tract was described only once in a patient with a recent diagnosis of HIV that affected the distal ileum and ascending colon. We will discuss the peculiarities of the case and the behavior of the immune system in the face of simultaneous opportunistic infections. This is a challenging scenario that has scarce publications and is of great clinical importance.

Tuberculosis presenting as broncho-oesophageal fistula in a young healthy man

A 21-year-old Saudi man presented with a history of dysphagia and choking. CT scan of the chest showed clear evidence of chronic recurrent aspiration pneumonia in the left lung. It also showed a fistula connecting the left main bronchus to the oesophagus. Endoscopy showed clear opening on the oesophageal side. Bronchoscopy also confirmed the presence of a broncho-oesophageal fistula on the left bronchial side with the presence of secretions on swallowing. Bronchoalveolar lavage (BAL) was done and sent for mycobacterial tuberculosis culture. The fistula was closed with clips under endoscopic guidance, which alleviated his symptoms of dysphagia and choking. The BAL culture grew mycobacterial tubercle bacilli. The patient showed marked improvement after starting antitubercular therapy and was discharged to be followed up in the clinic.

Mathew J, J. Michos L, Green P, M. Aman M. Using Bronchoscopy to Detect Acquired Tracheoesophageal Fistula in Mechanically Ventilated Patients

Introduction

An acquired Tracheoesophageal fistula (TEF) is commonly caused by a malignancy or trauma, with pulmonary infection or aspiration being the presenting symptom. However, in the critical care setting the presentation can be subtle and may present with difficult ventilation. High endotracheal tube cuff pressures can lead to tracheal erosions and thus increasing the chances for developing a TEF. Prolonged intubation in the presence of other risk factors like poor general state of health, episodic hypotension, nasogastric tubes, and repeated intubations can increase the likelihood of developing an acquired TEF. Angioedema of the airway is a rare but potentially devastating complication of angiotensin converting enzyme inhibitors (ACE-I) that could further add insult to the tracheal mucosa, predisposing to an acquired TEF.

Case Presentation

An elderly woman with multiple comorbidities and requiring mechanical ventilation, developed angioedema following intake of ACE inhibitor for hypertension. The ensuing airway edema made weaning off mechanical ventilation difficult. After repeated attempts at extubation, tracheostomy was performed. With the loss of airway after tracheostomy, the possibility of TEF was considered given her multiple risk factors and intra-operative findings of the tracheal mucosa.

Conclusions

While it may be difficult to predict who will actually develop a TEF, it is prudent to identify those at risk and take precautionary measures to prevent one. Emphasis should be placed on daily endotracheal cuff manometric pressure check to prevent ischemic changes of the tracheal mucosa resulting from high cuff pressures. Also, bronchoscopy could be used after extubating susceptible patients to detect an acquired TEF.

Tuberculous Bronchoesophageal Fistula Managed Conservatively with a Percutaneous Gastrostomy for Feeding and Administration of Medication

Bronchoesophageal fistulae are a rare complication of tuberculosis. Traditionally they are managed by either thoracotomy with resection and closure of the fistulous tract or by taking a more conservative approach of giving standard treatment for tuberculosis while ensuring nutritional support through a nasogastric tube. We report a young student with disseminated tuberculosis complicated by a bronchoesophageal fistula. He was managed conservatively with anti-tuberculous chemotherapy and nutrition administered through a percutaneous endoscopic gastrostomy tube. This approach was associated with a relatively good quality of life and he was able to pursue his studies uninterrupted at the local university.

Tracheomegaly and tracheosephagial fistula following mechanical ventilation: A case report and review of the literature

Postintubation Tracheoesophageal fistula (TEF) is a rare complication. Acquired TEF most commonly occurred following prolonged mechanical ventilation with an endotracheal or tracheostomy tube, cuff-related tracheal injury, post-intubation injury. We present a case of both tracheomegaly and tracheosephagial fistula following mechanical ventilation for 15 days, in the light of the literature.

Esophageal Microperforation due to Calcified Mediastinal Lymph Node Leading to Tracheoesophageal Fistula

A 42-year-old male presented with worsening gastroesophageal reflux disease symptoms and cough. The clinical symptoms during the early course of illness were striking for aspiration pneumonia. He was given a prescription of proton pump inhibitors and antibiotics. Rapid decline in the clinical condition with worsening respiratory status was noted. Worsening symptoms of fever, cough, and chest pain prompted further diagnostic work-up suggesting esophageal microperforation. Esophagogram was found to be suggestive of tracheoesophageal fistula. The tracheoesophageal fistula was due to subcarinal lymph node of nontuberculous origin.

An autopsy case of iatrogenic tracheoesophageal fistula secondary to tracheostomy

Tracheoesophageal fistula (TEF) is an uncommon but life-threatening sequel of prolonged use of a cuffed tracheostomy tube. We describe a patient who developed a TEF after a tracheostomy done for management of head injury due to a road traffic mishap. The patient subsequently died of sepsis after bilateral bronchopneumonia. To the best of our knowledge, this is the first autopsy case of iatrogenic TEF after tracheal intubation reported in forensic literature.