H-type tracheoesophageal fistula and congenital esophageal stenosis

Thoracoscopic treatment of congenital esophageal stenosis in combination with H-type tracheoesophageal fistula

Congenital esophageal stenosis combined with H-type tracheoesophageal fistula is a rare clinical entity that is often not diagnosed until months or sometimes many years after birth. We present a case of a boy who presented both these entities and was treated by thoracoscopy.

Congenital esophageal stenosis associated with esophageal atresia/tracheoesophageal fistula: clinical and radiologic features

BACKGROUND

Congenital esophageal stenosis (CES) can be associated with esophageal atresia/tracheoesophageal fistula (EA/TEF). Because there are a variety of degrees of obstruction and symptoms of CES, it is frequently difficult to make a pre- and post-operative diagnosis of the distal CES associated with EA/TEF.

OBJECTIVE

To evaluate the clinical and radiologic features of congenital esophageal stenosis associated with esophageal atresia/tracheoesophageal fistula.

MATERIALS AND METHODS

We retrospectively reviewed postoperative esophagograms and medical records of 187 children (107 boys, 80 girls) who had primary repair of EA/TEF from 1992 to 2009 at our institution. We evaluated the incidence of CES, clinical findings, radiologic features and management of CES in these children.

RESULTS

CES was diagnosed in 22 of 187 EA/TEF children (12%); one child had double CES lesions, for a total of 23 lesions. Ten of those 22 children (45%) had presented with significant symptoms of esophageal obstruction. The diagnosis of CES was delayed in 10 children (45%) until 1-10 years of age. On esophagogram, CES (n = 23) was located in the distal esophagus (n = 20, 87%) or mid-esophagus (n = 3, 13%). The degree of stenosis was severe (n = 6, 26%), moderate (n = 10, 43%), or mild (n = 7, 30%). Eight children, including two with unsuccessful esophageal balloon dilatation of CES, were treated surgically. Histologic examination revealed tracheobronchial remnant (n = 7) or fibromuscular hyperplasia (n = 1). One child with surgically treated CES developed achalasia at the age of 3 years 9 months.

CONCLUSION

Esophagography after EA/TEF repair should be performed with a high index of suspicion for the presence of distal CES, because the diagnosis and adequate management of CES can often be delayed.

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.

Sténose congénitale de l'œsophage par hétérotopie trachéobronchique : à propos de 2 cas et revue de littérature

Congenital esophageal stenosis due to tracheobronchial remnants is a rare malformation whose diagnosis may be difficult. It is characterised by the abnormal presence of congenital tissue of tracheal origin in the esophageal wall, which is responsible for the narrowing of the esophagus. We report 2 cases whose treatment was surgical after failure of esophageal dilations. The presence of tracheal-bronchial tissue was confirmed by histological examination of the operative piece. Outcome was favourable and the final result was excellent. Recently, endoscopic ultrasonography has been proved useful in the diagnosis of congenital esophageal stenosis due to tracheobronchial remnants by showing the presence of cartilage, which explains the failure of dilation. The high rate of perforation in these cases is due to brutal fragmentation of the cartilaginous rings. Surgical resection of esophageal stenosis with the tracheobronchial tissue appears the only treatment susceptible to completely suppress the stenosis and its consequences.

H-type tracheo-oesophageal fistula with congenital oesophageal stenosis

H-type tracheo-oesophageal fistula (H-TOF) and congenital oesophageal stenosis (COS) are both rare anomalies. Only six cases of H-TOF in association with COS have been described in the literature. Characteristically, diagnosis is delayed, often well beyond the neonatal period. We report a patient who was accurately diagnosed on day 12 of life, and outline several of the key clinical dilemmas encountered in managing a neonate with this combination of rare congenital anomalies.

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.

Clinical characteristics of congenital esophageal stenosis distal to associated esophageal atresia

BACKGROUND

Congenital esophageal stenosis (CES) has been reported to be a rare association in patients with esophageal atresia or tracheoesophageal fistula, or both (EA-TEF). This study investigates the clinical characteristics of this association with special reference to its treatment.

METHODS

A retrospective review of medical and radiographic records of 81 patients who underwent primary repair of EA-TEF was performed. An association of CES was diagnosed when they showed histologic evidence or persistent radiographic images of esophageal narrowing since the neonatal period.

RESULTS

Eleven of 81 EA-TEF patients (14%) were identified with CES. Their symptoms were difficulty in swallowing solid food, food impaction, emesis, stridor, repeated respiratory infection, and failure to thrive. Two patients had a recurrence of TEF. Three patients were diagnosed with CES in the neonatal period-2 at the time of primary repair of EA-TEF and 1 on the initial postoperative esophagram. The remaining 8 patients were diagnosed between the ages of 2 months and 3 years. Although esophageal dilatation was attempted in 9 patients, its effectiveness was temporary in all except 2 patients and esophageal laceration occurred in 4 patients. Surgical repair including myotomy and resection of the narrow segment was performed in 7 patients, in 6 of whom Nissen/Collis-Nissen fundoplication was added. A histologic examination was performed in 5 patients, revealing that their CES was due to fibro-muscular hypertrophy (2) or tracheobronchial remnants (3). The long-term outcome was satisfactory in all patients except one who showed wrap herniation.

CONCLUSIONS

The association between CES and EA-TEF is not rare. Esophageal dilatation was not universally effective and carried with it a considerable incidence of esophageal leakage. An antireflux operation concomitant with repair of CES may be useful to prevent postoperative gastroesophageal reflux in patients with a narrowing close to the esophagogastric junction.

The diagnosis and treatment of H-type tracheoesophageal fistula

BACKGROUND

H-type tracheoesophageal fistula (TEF) was diagnosed in 12 patients during the 25 years from 1971 to 1996. Although all patients were symptomatic since birth, in 58% of the cases, there was a diagnostic delay ranging from 26 days to 4 years.

METHODS

Esophagography and/or cineesophagography, or bronchoscopy and simultaneous methylene blue administration confirmed the diagnosis of H-type TEF. Although cineesophagography is highly effective in demonstrating H-type TEF today, bronchoscopy must be used in every patient suspected of having fistula, especially when the radiological methods fail. Bronchoscopy is helpful in diagnosis, in evaluation of associated respiratory tract anomalies, and in treatment.

RESULTS

Two newborn patients could not have been operated on because of pulmonary insufficiency resulting from delayed recognition of fistula. Ten patients underwent fistula repair, nine through cervical approach, and one through thoracotomy, with seven survivors.

CONCLUSIONS

The results suggest that early diagnosis is essential in the newborn period. Oversight in identification of H-type TEF, unsatisfactory radiological method, masquerading symptoms related to associated anomalies, and minute symptoms in some patients may cause delay in diagnosis. Radiological and endoscopic procedures are complementary in both diagnosis and treatment of H-type TEF.