Trans-tracheostomy repair of tracheo-esophageal fistula under endoscopic view in a 75-year-old woman

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.

Multidisciplinary team approach on tracheoesophageal fistula in a patient with home ventilator

A 68-year-old man was transferred to our tertiary hospital. Ten years ago, he received radiation therapy for tonsil cancer, and while there was no evidence of recurrence, he suffered from recurrent aspiration. We treated his aspiration pneumonia in the intensive care unit. Prior to his discharge, he received percutaneous dilatational tracheostomy (PDT) before he was transferred to a nursing hospital. Nine months later, he was readmitted owing to tracheoesophageal fistula (TEF). However, he was considered unsuitable for conservative intervention after a multidisciplinary team discussion. Esophageal stent insertion was impossible due to the high level of TEF in the esophagus. Additionally, the size of the TEF could not be covered by an endosponge and endoluminal vacuum therapy, and there was no tracheal stent that could cover his large trachea. The preceding percutaneous enteral gastrostomy (PEG) procedure was required for the primary closure operation of the esophagus; however, family's consent could not be obtained. After 1month, the patient and his family changed their minds and agreed to the procedure and we attempted to perform PEG procedure. However, we could not proceed with PEG owing to stenosis in the inlet of the esophagus. Then, the patient deteriorated clinically and died due to pneumonia with septic shock.

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.

Surgical repair of mechanical ventilation induced tracheoesophageal fistula

PURPOSE

To evaluate the outcomes of surgery to repair tracheoesophageal fistula (TEF) caused by mechanical ventilation.

METHOD

Case series and review of all cases reported in English literature. Only reports of TEF following mechanical ventilation and containing description of surgical repair and outcomes were included.

RESULTS

A total of 41 studies comprising 143 patients met the inclusion criteria. Most studies had incomplete information on important variables such as co-morbidity and fistula size. Tracheal resection anastomosis (TRA) was the most common approach, performed in 91 (63.6%) patients (including three newly reported here). Lateral approach repair (LA) was done in 45 (31.5%) patients. The former had a higher incidence of pre-existing tracheal stenosis [53 (89.8%) vs. 7 (35%) cases; p < 0.001]. Flap interposition to augment the repair was done in 49 (53.9%) and 40 (88.9%) cases, respectively (p < 0.001). Successful and durable healing of the fistula were achieved in 90 (98.9%) cases in TRA and 39 (88.6%) cases in LA.

CONCLUSION

In carefully selected cases of TEF caused by mechanical ventilation, TRA is the most preferred approach, delivering successful healing in almost all cases. Where TRA is not indicated or preferred, LA appears to be a good alternative. Future studies should explicitly report all of the known co-variables, so that the exact indications for choosing a particular surgical approach could be better elucidated.