Surgery for intrathoracic tracheoesophageal and bronchoesophageal fistula

Tracheoesophageal Fistula as a Complication of Prolonged Ventilation in COVID-19: Description of Reconstruction and Review of the Literature

Infection with COVID-19 pneumonia may necessitate intubation and mechanical ventilation. Viral inflammation and pressure necrosis may lead to scarring, stenosis, and in severe cases, fistula formation. Nonmalignant tracheoesophageal fistulas (TEF) represent a surgical challenge and may necessitate locoregional tissue transfer and tracheal resection to prevent recurrence and maintain airway patency. We present a case of TEF in a 63-year-old female secondary to prolonged mechanical ventilation in the setting of COVID pneumonia, detailing the clinical findings and surgical repair. Primary closure of the esophageal defect with pectoralis major muscle flap onlay and tracheal resection, with median sternotomy for access, provided successful intervention, allowing for subsequent tracheostomy decannulation and return to a complete oral diet. This case offers further evidence of the increased risk of airway complications in COVID-19 infection and provides otolaryngologists with an example of a rare surgical approach useful in management.

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.

Management and Discussion of COVID-19 Related Tracheal Stenosis: A Single Center Retrospective Review

SARS-CoV-2 virus has led to an unprecedented amount of tracheal stenosis. Rigid bronchoscopy can serve as a curative measure or bridge therapy to tracheal resection. We also briefly discuss the pathophysiology of tracheal stenosis from prolonged intubation and SARS-CoV-2 virus. This should be differentiated from other forms of airway obstruction such as tracheobronchomalacia which would be considered a pseudo-tracheal stenotic disease. The aim of this study is to evaluate stenosis that is unable to be improved with positive airway pressure or "PAP" therapies and required stenting and/or subsequent tracheal resection. By performing Rigid Bronchoscopy and subsequent stenting of airways, we demonstrated outcomes for long term airway patency regarding patients who were intubated secondary to the SARS-CoV-2 virus. We demonstrate superb outcomes in a consecutive case series of 6 patients managed with rigid bronchoscopy, airway stent and tracheal resection. The patients were all managed from a pulmonary perspective by the physicians mentioned in this study.

Management and outcomes in a consecutive series of patients with aero-digestive fistula at a tertiary gastro-esophageal surgery center

Aerodigestive fistula (ADF) is defined as a pathological connection between the upper digestive tract and the airway. ADF is associated with high morbidity and mortality and management is often complex. A cohort study including all patients admitted with ADF 2004-2022 at a single tertiary esophageal surgery center was performed based on prospectively collected administrative data and retrospectively collected electronic patient chart data,. Patient demographics, performance status, comorbidity, fistula characteristics, management, and outcomes in terms of morbidity and mortality were assessed in patients with ADF of three distinct types: (i) tumor overgrowth-related, (ii) various benign etiologies, and (iii) post-esophagectomy. Sixty-one patients with ADF were included in the study, 33 (54.1%) tumor overgrowth-related, six (9.8%) benign and 22 (36.1%) post-esophagectomy. In the post-esophagectomy group 15 out of 22 (68.2%) patients were diagnosed with anastomotic leakage prior to ADF diagnosis. Self-expandable metallic stents (SEMS) were used for temporary fistula sealing in 59 out of 61 (96.7%) patients, of which most received stents in both the digestive tract and airway. Temporary fistula sealing with stents was successful enabling discharge from hospital in 47 out of 59 (79.7%) patients. Definitive ADF repair was performed in 16 (26.2%) patients, of which one (6.3%) died within 90-days and 15 could be discharged home with permanently sealed fistulas. ADF is a complex condition associated with high mortality, which often requires multiple advanced interventions. SEMS can be applied in the airway and simultaneously in the digestive tract to temporarily seal the ADF as bridge to definitive surgical repair.

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.

Surgical strategies for benign acquired tracheoesophageal fistula

OBJECTIVES

Tracheoesophageal fistula (TEF) is characterized by abnormal connectivity between the posterior wall of the trachea or bronchus and the adjacent anterior wall of the oesophagus. Benign TEF can result in serious complications; however, there is currently no uniform standard to determine the appropriate surgical approach for repairing TEF.

METHODS

The PubMed database was used to search English literature associated with TEF from 1975 to October 2023. We employed Boolean operators and relevant keywords: 'tracheoesophageal fistula', 'tracheal resection', 'fistula suture', 'fistula repair', 'fistula closure', 'flap', 'patch', 'bioabsorbable material', 'bioprosthetic material', 'acellular dermal matrix', 'AlloDerm', 'double patch', 'oesophageal exclusion', 'oesophageal diversion' to search literature. The evidence level of the literature was assessed based on the GRADE classification.

RESULTS

Nutritional support, no severe pulmonary infection and weaning from mechanical ventilation were the 3 determinants for timing of operation. TEFs were classified into 3 levels: small TEF (<1 cm), moderate TEF (≥1 but <5 cm) and large TEF (≥5 cm). Fistula repair or tracheal segmental resection was used for the small TEF with normal tracheal status. If the anastomosis cannot be finished directly after tracheal segmental resection, special types of tracheal resection, such as slide tracheoplasty, oblique resection and reconstruction, and autologous tissue flaps were preferred depending upon the site and size of the fistula. Oesophageal exclusion was applicable to refractory TEF or patients with poor conditions.

CONCLUSIONS

The review primarily summarizes the main surgical techniques employed to repair various acquired TEF, to provide references that may contribute to the treatment of TEF.

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.

A successful repair of esophageal atresia (EA) with distal tracheoesophageal fistula (TEF) to a 6-day-old child in a low-resource setting. Case report

INTRODUCTION

Congenital tracheoesophageal fistula (TEF) is a rare and life-threatening anomaly that requires prompt surgical intervention. The case report highlights a successful TEF repair in setting with significant observed cases and low survival rate.

CASE PRESENTATION

We present a Type C Tracheoesophageal fistula successfully repaired by a conventional Open Surgical approach. An infant of 3 days born at term with Birth weight of 3 kg, presenting with postprandial regurgitation, choking and abdominal distension followed by early features of pneumonia. Initial chest X-ray with nasogastric (NS) tube catheter revealed features of esophageal atresia (EA) with distal TEF. An echocardiogram (ECHO) was performed, which revealed moderate patent ductus arteriosus (PDA) and small left to right shunt. A successful delayed primary repair was performed on the sixth day of life in the division of pediatric surgery center.

CONCLUSION

The successful outcome in this case serves as a testament to the dedication and resourcefulness of the healthcare team. It underscores the importance of high suspicious index, collaboration, adaptability, and skill in providing quality care in low-resource settings, reaffirming the possibility of saving lives even in challenging circumstances.

Infant Pneumonitis Due to a Tracheoesophageal Fistula: A Presentation of Two Autopsy Cases

Both esophageal atresia (EA) and tracheoesophageal fistula (TEF) represent a rather uncommon congenital abnormality that is the result of abnormal tracheoesophageal organogenesis. Although EA, with or without TEF, is relatively uncommon, it represents the most common upper gastrointestinal birth defect. Esophageal atresia and tracheoesophageal fistula are anatomically classified into five types according to the Gross classification (types A, B, C, D, E/H). As in type E/H, the continuity of the esophagus is not interrupted, the symptom onset is consequently delayed, and therefore diagnosis is difficult. Aspiration pneumonitis is a chemical injury caused by inhaled sterile gastric contents, while aspiration pneumonia is, in part, an infectious process because the inhaled oropharyngeal secretions are rich in bacteria. This paper aims to report two infant autopsy cases of aspiration pneumonitis with TEF involvement. The main histopathological finding was interstitial pneumonitis. Upon histopathological examination, lymphocytes, plasma cells, and macrophages were discovered on the alveolar walls, which were compatible with the chemical origin of interstitial pneumonitis. No eosinophils were detected; therefore, hypersensitivity-originating interstitial pneumonitis was ruled out. The cause of death in both cases was interstitial pneumonitis.

A Multidisciplinary Approach to Tracheoesophageal Fistula Repair in a Newborn: A Case Report

This case report details the emergency management and successful surgical repair of a tracheoesophageal fistula (TEF) in a newborn delivered by lower segment cesarean section. Despite immediate crying after birth, the neonate's distress was evident, with an Apgar score of 4, prompting an urgent referral to the Neonatal ICU (NICU). Diagnostic investigations, including ultrasonography and two-dimensional echocardiography (2D Echo), revealed associated anomalies, such as a patent ductus arteriosus, arterial septal defect, and a TEF. An anaesthetist was urgently involved due to postnatal desaturation, leading to challenging intubation and surgical repair performed under general anaesthesia, which involved separating the trachea from the oesophagus. Postoperative imaging confirmed the successful closure of the fistulous connection. This case highlights the significance of prompt diagnosis, collaborative management, and surgical intervention in optimising outcomes for neonates with complex congenital anomalies like TEF.

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.

Post-esophagectomy tracheobronchoesophageal fistula: management and results of a tertiary referral center

A tracheobronchoesophageal fistula (TBEF) is a rare but life-threatening complication after esophagectomy. The existing literature on TBEF management is limited and many previous recommendations are contradictory. We aimed to describe our series of TBEF after esophagectomy and compare it with other reported series. Patients who developed a TBEF after esophagectomy were identified retrospectively. Baseline and intraoperative characteristics, postoperative and TBEF details, treatments for TBEF, and main outcomes are described. A univariate analysis was performed to compare some of the analyzed variables with the overall sample. Finally, our results are compared with the previously described series. Altogether, 16 patients with TBEF (3.11%) were analyzed from 514 patients who received esophagectomies between January 2014 and February 2020. As a first treatment attempt, 14 (87.5%) were treated with surgery, one was treated conservatively, and one was treated endoscopically. Surgery both at a first or second treatment attempt achieved a survival rate of 62.5% and oral intake at discharge of 43.75%. Six patients died during their hospital stay (37.5%). The presence of an anastomotic leak showed a strong association with TBEF development (100% vs. 19.7%; OR 1.163, 95% CI 1.080-1.253, p = 0.000). In our experience, surgical treatment as the first approach for TBEF associated with anastomotic leak after esophagectomy obtained good results. However, there is an urgent need to elaborate treatment guidelines based on international consensus.

[Treatment of tracheoesophageal fistula and consequences of severe spinal injury]

Modern approaches to intensive care and anesthesiology make it possible to save patients with various severe traumas. Prolonged mechanical ventilation allows stabilizing the patient's status, but can result severe complications including tracheoesophageal fistula. Our patient received severe combined injury after road accident, i.e. compression-comminuted fractures of DIV, DV, DVI vertebrae with spinal cord compression, ThIII compression fracture, compression-comminuted fracture of bodies and arches ThIV, V, VI with ThVI dislocation, lower paraplegia and pelvic organ dysfunction, left-sided laryngeal paresis, brain concussion and contusion of both lungs. Mechanical ventilation has been performed for 1.5 months. The patient suffered inflammatory complications: bilateral pneumonia complicated by right-sided pleural empyema, sepsis, tracheostomy suppuration followed by cervical soft tissue abscess. Pleural drainage and debridement, as well as drainage of abscess were performed. At the same time, we diagnosed external esophageal fistula at the CVII level. Tracheoesophageal fistula closure via cervical access was carried out at the first stage. Postoperative period was uneventful. After 20 days, we performed spondylosynthesis ThI-ThVII, and decompression laminectomy ThIV-ThVI. Spine stabilization by metal elements has a beneficial effect even without spinal cord recovery regarding better conditions for neurological and social rehabilitation. Thus, treatment was performed in a highly specialized multi-field hospital by thoracic surgeons and vertebrologists. We realized the treatment plan and obtained favorable results with minimal risk of postoperative complications.

MANAGEMENT OF COMPLICATIONS FOLLOWING BUTTON BATTERY INGESTION

Ingestion of button batteries by children is increasing every year, which is becoming a clinical problem for pediatricians. The number of complications and mortality when using batteries exceeds similar indicators when accidentally swallowing other foreign bodies. This is due to the electrochemical and mechanical effect of the battery on the mucous membrane of the gastrointestinal tract and especially the esophagus. With a late diagnosis, an ordinary battery leads to the development of fatal complications. In modern literature, there are no protocols that would relate to the treatment of similar situations, in particular, in the development of a tracheoesophageal fistula. The article describes a case of successful treatment of a tracheoesophageal fistula due to a long-term stay of a battery in the esophagus. This condition was also complicated by the development of bilateral tension pneumothorax. The dilemma in such cases is always difficult: to choose operative or conservative treatment. Both methods have their advantages and disadvantages. In this clinical case, preference was given to conservative treatment, which ended quite successfully. But the main goal is to prevent such situations. This can be achieved by raising parents' awareness of the risks of battery ingestion. Also, the efforts of a doctor who is faced with a similar situation should be directed to the fastest possible diagnosis and removal of such a foreign body as a battery.

Tracheo-esophageal fistula and pleural empyema in the course of SARS-CoV-2 infection-A case report

We report a 49-year-old patient with COVID-19 who developed lung abscess, pleural empyema, and tracheo-esophageal fistula. He underwent cervicotomy, segmental tracheal resection, esophageal-tracheal fistula excision, and suturing the esophagus, and a classic thoracotomy was performed. Despite the severe infection, the patient was discharged home after successful surgical treatment.

Diagnosis and Management of Button Battery Ingestion Complicated by Tracheo-Esophageal and Aorto-Esophageal Fistulas

Button battery ingestion (BBI) is common in children and its prevalence has increased in the last decades. BBI can be responsible for very severe and potentially fatal complications if not promptly detected. We describe the successful management of two cases of BBI that occurred in two previously healthy infants. Both patients presented with vague symptoms and no witness of foreign body ingestion. The prolonged time of exposure to the corrosive effects of disk batteries was responsible for the development of tracheo-esophageal fistula (TEF) and aorto-esophageal fistula (AEF). We demonstrate how prompt diagnosis and management are crucial for the infants’ survival.

Tracheobronchial Surgery in Emerging Countries

Tracheobronchial surgery is widely performed in emerging countries mainly as a consequence of the high number of airway-related complications and poor management in intensive care units. This has led to great expertise in the surgical management of postintubation tracheal stenosis, and opportunity for advancing scientific knowledge. Nonetheless, tracheal stenosis has a severe impact on a patient's quality of life, is a major burden to the health system, and should be prevented. Incorporation of innovative techniques, technologies, and prospective databases should prompt earlier diagnosis and lead to fewer complications.

Analysis of the Application Value of Different Esophagography Techniques in the Diagnosis of H-Type Tracheoesophageal Fistula in Neonates

Objective

The study aimed to analyse the detection rates of the triple-lumen double-balloon catheter technique and conventional esophagography in diagnosing H-type tracheoesophageal fistula (H-TEF) in neonates.

Methods

The data of 8 neonates diagnosed with H-TEF by surgery in the researchers' hospital between January 2015 and January 2022 were collected. We compared the detection (true positive) rates of H-TEF by the triple-lumen double-balloon catheter technique, conventional esophagography, and multidetector row spiral CT.

Results

Before surgery, conventional esophagography was applied in all 8 cases, of which the H-TEF diagnosis was confirmed in 5 cases and TEF was suspected in 3 cases. The triple-lumen double-balloon catheter technique was employed in 5 cases, of which 4 were confirmed with H-TEF and 1 was suspected with TEF. Multidetector row spiral CT was performed in 4 cases, and 1 case was confirmed with H-TEF, while no fistula was observed in the other 3 cases. The triple-lumen double-balloon catheter technique yielded a 100% detection rate, while conventional esophagography revealed a 62.5% rate and multidetector row spiral CT showed a 25% rate. By comparative analysis, the true positive rates (TPRs) of the triple-lumen double-balloon catheter technique and conventional esophagography were not significantly different (P=0.118). No significant differences were recorded in TPRs between conventional esophagography and multidetector row spiral CT (P=0.221). However, the triple-lumen double-balloon catheter technique had a significantly higher TPR than multidetector row spiral CT (P=0.118).

Conclusion

To diagnose congenital H-TEF in neonates, conventional esophagography is a highly valuable yet inconsistently reliable method and the diagnostic value of CT is relatively limited. The triple-lumen double-balloon catheter technique boasts a significantly valuable application for H-TEF diagnosis. Being simple, economical, and effective, it barely requires state-of-the-art facilities, and no complications have occurred during its clinical practice. These advantages justify a possible wider application of the triple-lumen double-balloon catheter technique in clinical practice.

Repair of a three-way congenital bronchoesophageal fistula in an adult patient: a case report

BACKGROUND

The incidence of congenital bronchoesophageal fistulas in adults is rare. Most fistulas discovered in adulthood are often small and can be repaired with a simple one-step method.

CASE PRESENTATION

A 46-year-old female patient complained of a 2-month history of chocking, coughing, and a 12 kg drop in weight. The bronchofiberscopy and gastroscopy showed a large fistula, which extended from the esophagus to the main bronchus on both sides, thus forming a special three-way channel which has never been reported. This case was challenging both to the anesthetists and surgeons. The patient was intubated with a sengstaken-blakemore tube, and then received segmental esophageal resection, anastomotic reconstruction, and double-flap repair with esophagus segment in situ.

CONCLUSION

When the fistula in BEF is large or complicated, appropriate surgical methods should be meticulously designed according to the condition of the patient. The problem of anesthesia intubation should be solved first, to allow a smooth operation. Secondly, a double-layer repair of the airway fistula by using esophageal wall tissues as patch materials is proposed.

Acquired tracheoesophageal fistula in a pregnant patient with COVID-19 pneumonia on prolonged invasive ventilation

A previously healthy pregnant woman was diagnosed with COVID-19 pneumonia and was subsequently intubated. Throughout the course of her illness, the patient was treated for recurrent bouts of pneumonia. A high-resolution chest and neck CT scan confirmed the presence of a tracheoesophageal fistula (TEF), which may have been caused by the presence of the overinflated endotracheal cuff, prolonged steroid use, hypoxic injury and possible direct injury of the tracheal mucosa from COVID-19 itself. A temporising procedure, involving tracheostomy with an extended-length tracheal tube, was performed. Unfortunately, the patient succumbed to infection prior to definitive repair. This case highlights the importance of keeping a high index of suspicion for tracheal injury in patients who experience prolonged periods of intubation. It also underlies the high morbidity and mortality rate associated with TEF, although being a rare disease.

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.

Identification of acquired tracheoesophageal fistula after tracheostomy decannulation by videofluoroscopic swallowing study: A case report

RATIONALE

Videofluoroscopic swallowing study (VFSS) is a noninvasive radiographic procedure that examines the oral, pharyngeal, and cervical esophageal stages of swallowing. Tracheoesophageal fistula (TEF) is difficult to diagnose depending on its size and location. However, how VFSS can be of benefit in the diagnosis of TEF has not been reported yet.

PATIENT CONCERNS

A 64-year-old man who had been tracheostomized post spinal tumor resection surgery at the cervical level 1 to 2, had his tracheostomy tube removed approximately 25 years ago. After decannulation, he reported coughing while swallowing food, foreign sensation in the neck and repeated bouts of pneumonia ever since.

DIAGNOSIS

VFSS revealed, for the first time, acquired TEF after tracheostomy decannulation as the cause of repetitive aspiration pneumonia.

INTERVENTION

VFSS was performed in this case.

OUTCOMES

In the background of suspected TEF based on VFSS results, the patient underwent a computed tomography scan of the chest and airway in the prone position, followed by bronchoscopy, which confirmed the existence of a TEF. He then underwent primary closure of the fistula. The patient had an uneventful recovery and is currently symptom-free 10 months after the surgery.

LESSONS

This case alerts clinicians to the possibility of TEF as a diagnosis when the aspirate leaks from the upper esophagus and through the posterior wall of trachea in the esophageal phase of VFSS.

Evaluation of the Incidence and Potential Mechanisms of Tracheal Complications in Patients With COVID-19

Importance

Full-thickness tracheal lesions and tracheoesophageal fistulas are severe complications of invasive mechanical ventilation. The incidence of tracheal complications in ventilated patients with coronavirus disease 2019 (COVID-19) is unknown.

Objective

To evaluate whether patients with COVID-19 have a higher incidence of full-thickness tracheal lesions and tracheoesophageal fistulas than matched controls and to investigate potential mechanisms.

Design, Setting, and Participants

This is a retrospective cohort study in patients admitted to the intensive care unit in a tertiary referral hospital. Among 98 consecutive patients with COVID-19 with severe respiratory failure, 30 underwent prolonged (≥14 days) invasive mechanical ventilation and were included in the COVID-19 group. The control group included 45 patients without COVID-19. Patients with COVID-19 were selected from March 1 to May 31, 2020, while the control group was selected from March 1 to May 31, 2019.

Exposures

Patients with COVID-19 had severe acute respiratory syndrome coronavirus 2 infection diagnosed by nasopharyngeal/oropharyngeal swabs and were treated according to local therapeutic procedures.

Main Outcomes and Measures

The primary study outcome was the incidence of full-thickness tracheal lesions or tracheoesophageal fistulas in patients with prolonged invasive mechanical ventilation.

Results

The mean (SD) age was 68.8 (9.0) years in the COVID-19 group and 68.5 (14.1) years in the control group (effect size, 0.3; 95% CI, -5.0 to 5.6). Eight (27%) and 15 (33%) women were enrolled in the COVID-19 group and the control group, respectively. Fourteen patients (47%) in the COVID-19 group had full-thickness tracheal lesions (n = 10, 33%) or tracheoesophageal fistulas (n = 4, 13%), while 1 patient (2.2%) in the control group had a full-thickness tracheal lesion (odds ratio, 38.4; 95% CI, 4.7 to 316.9). Clinical and radiological presentations of tracheal lesions were pneumomediastinum (n = 10, 71%), pneumothorax (n = 6, 43%), and/or subcutaneous emphysema (n = 13, 93%).

Conclusions and Relevance

In this cohort study, almost half of patients with COVID-19 developed full-thickness tracheal lesions and/or tracheoesophageal fistulas after prolonged invasive mechanical ventilation. Attempts to prevent these lesions should be made and quickly recognized when they occur to avoid potentially life-threatening complications in ventilated patients with COVID-19.

Muscle Flap Transposition for the Management of Intrathoracic Fistulas

BACKGROUND

Intrathoracic fistulas pose unique challenges for thoracic and reconstructive surgeons. To decrease the incidence of fistula recurrence, pedicled flaps have been suggested to buttress the repair site. The authors aimed to report their experience with muscle flap transposition for the management of intrathoracic fistulas.

METHODS

A retrospective review of all patients who underwent intrathoracic muscle flap transposition for the management of intrathoracic fistulas from 1990 to 2010 was conducted. Patient demographics, surgical characteristics, and complication rates were abstracted and analyzed.

RESULTS

A total of 198 patients were identified. Bronchopleural fistula was present in 156 of the patients (79 percent), and 48 had esophageal fistula (24 percent). A total of 238 flaps were used, constituting an average of 1.2 flaps per patient. After the initial fistula repair, bronchopleural fistula complicated the course of 34 patients (17 percent), and esophageal fistula occurred in 13 patients (7 percent). Partial flap loss was identified in 11 flaps (6 percent), and total flap loss occurred in four flaps (2 percent). Median follow-up was 27 months. At the last follow-up, 182 of the patients (92 percent) had no evidence of fistula, 175 (89 percent) achieved successful chest closure, and 164 (83 percent) had successful treatment. Preoperative radiation therapy and American Society of Anesthesiologists score of 4 or greater were identified as risk factors for unsuccessful treatment.

CONCLUSIONS

Intrathoracic fistulas remain a source of major morbidity and mortality. Reinforcement of the fistula closure with vascularized muscle flaps is a viable option for preventing dehiscence of the repair site and can be potentially life-saving.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Bronchoesophageal fistula secondary to postpneumonectomy like syndrome caused by bilobectomy and postoperative radiation therapy for lung cancer

Postpneumonectomy like syndrome is a very rare condition and benign bronchoesophageal fistula (BEF) is also uncommon in the adult. Therefore, the probability of occurrence of BEF secondary to postpneumonectomy like syndrome will be extremely rare, and has not been reported yet in the literature. This is the first case report of postpneumonectomy like syndrome combined BEF after bilobectomy and postoperative radiation therapy for lung cancer.

Health-related quality of life evaluation in patients with non-surgical benign tracheal stenosis

Background

The primary objective of the study was to evaluate the health-related quality of life (HRQL) of patients with benign post-intubation tracheal stenosis considered as unfit for surgical treatment. Secondary objectives were: (I) to determine if clinical variables (gender, age, total treatment time, and type of tracheal device) could influence HRQL and (II) to compare the results with a normal standardized population.

Methods

Prospective study between August-2014 and December-2016 including patients with tracheal stenosis treated with silicone stents, T-Tubes or tracheostomy. Candidates to airway resection and reconstruction were excluded from the analysis. HRQL was assessed with the SF-36 Health Questionnaire. Backward stepwise regression model analyzed the influence of clinical variables on the SF-36 domains and component summaries. Norm-based results were compared with normative data. Alpha error was 5%.

Results

Ninety-three patients (62M/31F; mean age 38±14 years) were included. Mean overall HRQL in all 8 SF-36 domains was poor. Lowest scores were in the role physical (mean 31.7±38), bodily pain (mean 39.2±35), and role emotional domain (mean 48.7±40). The physical component summary (PCS) was more affected than the mental (P<0.001). Norm-based results indicated that most domains and both physical and mental summaries were below the mean for the USA normative population. Total stenting time significantly influenced the physical (P=0.001) and mental component summaries (P=0.001).

Conclusions

Quality of life of patients with benign tracheal stenosis is severely impaired, and norm-based results indicate that the HRQL is below normative data. Physical and mental discomfort seems to be attenuated by total treatment time.