Acquired tracheoesophageal fistula in infancy and childhood

Evaluating the management timeline of tracheoesophageal fistulas secondary to button batteries: A systematic review

INTRODUCTION

During the SARS-CoV-2 pandemic, the incidence of pediatric button battery (BB) ingestions has risen. Children have spent more time at home from school, while many parents try to balance working from home and childcare. Additionally, the amount of electronics powered by BB has increased. Tracheoesophageal fistula (TEF) secondary to a retained aerodigestive BB is a devastating development. Management is challenging, and the clinical timeline of watchful waiting versus surgical intervention for TEF is poorly defined in the literature.

METHODS

In accordance with PRISMA guidelines, databases searched include PubMed, Scopus, and CINAHL from database date of inception through August 13, 2021. All study designs were included, and no language, publication date, or other restrictions were applied. Case series and reports of TEFs secondary to BBs were included. Clinical risk factors and outcomes were compared between the spontaneous closure and surgical repair groups.

RESULTS

A total of 79 studies with 105 total patients were included. Mortality was 11.4%. There were 23 (21.9%) TEFs that spontaneously closed and 71 (67.6%) that underwent surgical repair. Median time to spontaneous closure compared to surgical repair was significantly different (8.0 weeks [IQR 4.0-18.4] vs. 2.0 weeks [IQR 0.1-3.3], p<0.001). Smaller TEFs were more likely to spontaneously close versus being surgically repaired (9.3 mm ± 3.5 vs. 14.9 mm ± 8.3, p=0.022). Duration of symptoms before BB discovery, BB size, time between BB removal and TEF discovery, and location of the TEF were not statistically different between the spontaneous closure and surgical repair groups.

CONCLUSION

A TEF secondary to BB ingestion is a potentially deadly complication. Timing of reported TEF spontaneous closure varies significantly. While smaller TEFs may be amenable to healing without surgical repair, no other significant factors were identified that may be associated with spontaneous closure. If clinical status permits, these data suggest a period of observation of at least 8 weeks prior to surgical intervention may be practical for many BB-induced TEFs.

Atypical presentation of acquired tracheo-oesophageal fistula in an adolescent girl with pulmonary tuberculosis

We report a case of an adolescent girl presenting with acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. Initial presentation during the ongoing COVID-19 pandemic was compatible with multisystem inflammatory response in children associated with COVID-19 (MIS-C). Subsequently a diagnosis of tuberculosis was made. During ventilation, she developed significant abdominal distension which was not relieved with nasogastric decompression. There was a high index of suspicion of bronchoenteric fistula. Bronchoscopy with adjunct oesophagoscopy demonstrated tracheo-oesophageal fistula (TEF). The classical presentation of TEF has been masked by onset of ARDS. During the pandemic the diagnosis of tuberculosis in high-burden countries decreased for multiple reasons leading to development of complications which are often confused with MIS-C. While diagnosing MIS-C, maintaining a high level of suspicion for concomitant or alternative aetiologies is essential.

Slide Tracheoplasty for Repair of Complex Tracheoesophageal Fistulas

OBJECTIVES/HYPOTHESIS

Repair of large, recurrent, and complex tracheoesophageal fistulas (TEFs) is challenging and numerous different surgical approaches exist. These various techniques each carry a set of risks and possible complications such as fistula recurrence, tracheal stenosis or pouches, esophageal stenosis, and recurrent laryngeal nerve injury. Slide tracheoplasty is a reconstructive technique successfully used in many different airway pathologies, including TEF repair. This study examines the success, limits, and complications related to slide tracheoplasty for repair of complex TEFs.

STUDY DESIGN

Retrospective chart review.

METHODS

Patients undergoing TEF repair using a cervical or thoracic approach slide tracheoplasty, at a single institution, between July 2008 and December 2019 were retrospectively reviewed. Demographic data, comorbidities, TEF etiology and surgical history, slide tracheoplasty details and outcomes, and postoperative complication data were examined using descriptive statistics.

RESULTS

Twenty-six patients underwent 27 slide tracheoplasties for TEF (20 cervical approaches, 7 thoracic approaches) with a mean age of 5.2 years (IQR 0.7-7.6) at time of surgery. The most common TEF etiologies included congenital (n = 13), tracheostomy tube erosion (n = 5), and button battery ingestion (n = 4). Fistulas ranged in size from <0.5 mm to 4 cm and 59% had previous endoscopic or open repairs. There were two TEF recurrences (7.4%), one of which was successfully revised and the other which was treated with stent placement. Postoperative complications included dehiscence (3.7%), unilateral vocal fold paralysis (3.7%), and mild tracheal stenosis (18.5%).

CONCLUSIONS

Slide tracheoplasty is an effective surgical technique for treating complex congenital and acquired TEFs with lower rates of complications when compared to other techniques.

LEVEL OF EVIDENCE

IV Laryngoscope, 2021.

Management of acquired tracheoesophageal fistula with various clinical presentations

PURPOSE

To determine the best therapeutic approach for acquired tracheoesophageal fistulae in childhood by evaluation of distinct clinical presentations requiring different surgical management based on our clinical experience.

PATIENTS AND METHODS

Seven patients with acquired tracheoesophageal fistula seen between 1999 and 2010 were retrospectively studied with regard to the presenting findings, diagnostic evaluation, therapeutic approach, and outcomes.

RESULTS

Five girls and two boys with a median age of 36 months (range, 2-156 months) were treated for acquired tracheoesophageal fistula. The presenting symptoms were respiratory difficulty (n = 3), coughing (n = 2), and dysphagia with coughing (n = 2), with a median duration of 30 days (range, 1-730 days). The etiologies were disc battery ingestion (n = 3), placement of endoesophageal prosthesis for caustic esophageal stricture (n = 2), corrosive ingestion with extensive burn (n = 1), and blunt chest trauma with subsequent emergency tracheotomy (n = 1). The site of the fistulae were proximal (n = 3) and middle (n = 1) trachea, left main bronchus (n = 1), and nearly the entire posterior wall of the trachea (n = 2). The patients were variously managed: conservatively with eventual spontaneous closure (n = 1), primary repair (n = 2), and colon interposition after cervical esophagostomy (n = 4) based on the clinical evaluation on admission and the follow-up status. Stenosis of the proximal esophagus (n = 2) and esophagocolonic anastomosis (n = 2) were the only complications encountered after treatment and were successfully managed with dilatation.

CONCLUSIONS

The best therapeutic approach for acquired tracheoesophageal fistula can be determined with careful consideration of relevant parameters on admission, including medical history, presenting findings, etiology, and characteristics of the fistula, in addition to the clinical evaluation in the follow-up period. In general, conservative management should precede definitive surgical intervention both to allow for possible spontaneous closure and also to achieve optimal preoperative status. Primary repair or a staged surgical approach can be best selected by giving priority to the patient's airway security.

Acquired tracheoesophageal fistula during treatment for pediatric acute lymphoblastic leukemia

Management of pediatric malignancy can result in disruption of the integrity of the gastrointestinal mucosa through a variety of mechanisms. We describe a pediatric oncology patient who developed a tracheoesophageal fistula as a complication of treatment for acute lymphoblastic leukemia.

Usefulness of large pleural flap for the treatment of children with recurrent tracheoesophageal fistula

PURPOSE

Recurrent tracheoesophageal fistula (RTF) complicates 5-11% of cases of children treated at birth for esophageal atresia with inferior tracheoesophageal fistula (ITF), and it represents an important problem of respiratory morbility and mortality. Surgical correction of RTF is complex with high incidence of recurrence. The aim of this work is to demonstrate the usefulness of large vascularized pleural flap in the treatment of RTF and the prevention of recurrences.

METHODS

From 2000 to 2007, four children (3 males and 1 female) referred to our hospital for respiratory symptoms secondary to RTF. Diagnosis of RTF was made by bronchoscopy and esophagogram with contrast medium. Operative repair involved resection of the fistula, suture of trachea and esophagus followed by interposition of large vascularized pleural flap (PF).

RESULTS

There were no complications during surgical procedure and after 48 h, with easy respiratory weaning after 24 h. Hospital discharge ranged from 5 to 10 days. Long-term follow-up (range 18 months-5 years) demonstrated no evidence of recurrences.

CONCLUSION

Large vascularized PF to closure RTF is a highly effective and physiologic method for preventing second recurrences.

Acquired tracheoesophageal fistula following disc-battery ingestion: can we watch and wait?

Acquired tracheoesophageal fistulas (TEF) are rare but dangerous complications of disc-battery ingestion. Management approaches include endoscopic or open surgical repair. Unfortunately, these procedures can be complicated by high rates of recurrent laryngeal nerve injury, tracheal stenosis, recurrent fistula and significant patient mortality. Thus, several authors have advocated the use of esophageal rest as conservative management of acquired TEF to permit closure by secondary intention. This study describes a patient with spontaneous closure of an acquired TEF following disc-battery ingestion. The late recurrence of the TEF following conservative management, and endoscopic and radiographic evidence of closure, illustrates the importance of long term evaluation before assuming fistula resolution. Practitioners must carefully weigh the risks and benefits before deciding surgical versus conservative management of TEF. An extended follow-up of at least 6 months should be instituted with a high index of suspicion if conservative management is utilized. Transtracheal repair using an imbricated suture technique is a good surgical option when conservative management fails.

Complication of mediastinal mass: acquired tracheoesophageal fistula associated with T-cell lymphoblastic lymphoma

The occurrence of a tracheoesophageal fistula (TEF) in the setting of lymphoma has only rarely been reported in the world literature. Most cases reported were associated with radiation therapy vs. chemotherapy alone. This report presents one case illustrating the difficulty encountered managing a TEF that developed while undergoing chemotherapy for T-cell lymphoblastic lymphoma.

Anesthetic management of the complications of previously undiagnosed ingested foreign body in a pediatric patient

A case of a previously undiagnosed ingested foreign body, subsequent acquired tracheoesophageal fistula and airway obstruction in a pediatric patient is described. We suggest that the capability to provide cardiopulmonary bypass was a key factor in this patient's survival.

Pistachio nutshell foreign body of the oral cavity in two children

Pistachio nutshell foreign bodies have been documented in the literature, occurring most commonly in the bronchi. The objective of this study is to report on two cases of oral cavity lesions, which were subsequently found to be pistachio nutshell foreign bodies. The first patient is a 9-month-old male who presented with a hard palate mass measuring 1.5 cm. The patient was evaluated in the operating room, and found to have a submucosal pistachio nutshell foreign body. The second patient is a 17-month-old female who presented with a firm, fixed midline hard palate mass. The lesion was subsequently noted to dislodge from the palate, and was identified as a pistachio nutshell.

Acquired tracheo-esophageal fistulas caused by button battery lodged in the esophagus

Esophageal impacting of button batteries must be distinguished from impacting of other foreign bodies because of their severe complications. We present a 2.5-year-old girl who had an acquired tracheo-esophageal fistula (TEF) caused by a calculator battery lodged in her esophagus. We also review the literature and assess the applicability of multislice CT and its possible advantages in children with acquired TEF.

Esophagotracheal fistula after lithium disc battery ingestion successfully treated with hyperbaric oxygen therapy

We report a case of a 12-month-old child who acquired an esophagotracheal fistula of 5 mm in diameter after an ingested lithium disc battery impaction. Failure to recognize foreign body on chest X-rays resulted in a delay of 28 days in establishing the diagnosis. Feeding via nasogastric tube and hyperbaric oxygen treatment (HBOT) resulted in a complete closure of the fistula after 17 HBOT 60 min sessions at 2.2 bars.

Rare case of spontaneous closure of tracheo-esophageal fistula secondary to disc battery ingestion

Accidental ingestion of foreign bodies by children is not an uncommon event. Now a day, with increasing accessibility of electronic toys and devices to the children, ingestion of miniature size batteries is on the rise [J. Am. Med. Assoc., 249, (1983), 2495]. Unlike the usual foreign bodies, ingestion of button alkaline batteries may be associated with serious complications if not removed early [Am. J. Otolaryngol., 21 (2000) 333]. We report a rare and interesting case, in which a child developed tracheo-esopbageal fistula secondary to disc battery ingestion, and importantly, its conservative management resulting in its spontaneous closure.

Anesthetic management of acquired tracheoesophageal fistula: a brief report

IMPLICATIONS

Tracheoesophageal fistula may be either a congenital lesion or an acquired condition, most often resulting from foreign body ingestion. Location of the lesion has implications for anesthetic management and single lung ventilation may be required to facilitate surgical repair. In pediatric patients, intentional mainstem intubation may be required.

Spontaneous closure of acquired tracheo-oesophageal fistula

Acquired tracheo-oesophageal fistulae are uncommon in the paediatric age group. A case of such a fistula secondary to impaction of a button battery is reported below. Prompt management is essential to reduce morbidity and mortality in these cases.

Management of tracheoesophageal fistula as a complication of esophageal dilatations in caustic esophageal burns

The authors report on eight patients with caustic esophageal burns in whom tracheoesophageal fistula (TEF) developed during dilatation programs. This study covered a period of 17 years between 1975 and 1992. The age of the patients ranged from 1.5 to 8 years (mean age, 3.4 years). TEF developed after 5 to 43 months after injury (mean, 20.05 months). In each case, after documentation of the fistula by esophagography, esophagoscopy, and/or bronchoscopy, the fistula was blocked by an intraluminal esophageal stent, a polytetrafluoroethylene (PTFE) tube with a large lumen (10-mm diameter maximum). In this period, patients were fed via a jejunostomy tube and by total parenteral nutrition (TPN) if indicated, while the existing pneumonia was being treated. In one patient, fistula closed spontaneously during the stent application program, which ended with a patent esophagus. In two patients primary closure of TEF was attempted. In one of them fistula recurred and in the other it was technically impossible to separate the esophagus from trachea safely because of the very tight adhesions. In five patients a two-stage coloesophagoplasty was performed to bypass the fistulated esophagus. In the first stage, retrosternal pull-through of the colon and coloesophagogastric anastomosis was performed. In the second stage, closure of the distal esophagus and cervical coloesophagostomy was carried out. The patient with the primary closure attempt and one patient with stage 1 coloesophagoplasty died 3 and 4 months, respectively, after the operations. The cause of death was uncontrollable pneumonia in both cases. Follow-up of the four patients showed no complications. Another fistula patient is currently on stent treatment program with pneumonia under control.(ABSTRACT TRUNCATED AT 250 WORDS)