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Sánchez Sánchez Á, Aranda García MJ, Ruiz Pruneda R, Sánchez Morote JM. Acute gastric volvulus secondary to H-type tracheo-oesophageal fistula. BMJ Case Rep 2024; 17:e259719. [PMID: 38839416 DOI: 10.1136/bcr-2024-259719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
H-type tracheo-oesophageal fistula is an uncommon type of tracheo-oesophageal malformation. Acute gastric volvulus is another infrequent pathology in children. They rarely present together.We report the case of a toddler with acute gastric volvulus possibly secondary to an undiagnosed H-type tracheo-oesophageal fistula. The fistula was suspected due to persistent gastric distention observed during volvulus detorsion. This kind of tracheo-oesophageal fistula often presents with subtle symptoms making early diagnosis difficult.Acute gastric volvulus is a life-threatening condition. Gastric distension caused by the passage of air into the stomach through the fistula could be a triggering factor for gastric volvulus.
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Affiliation(s)
| | | | - Ramón Ruiz Pruneda
- Pediatric Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
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2
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Morchio C, Ganarin A, Conforti A, Leva E, Gaglione G, Brenco G, Zambaiti E, Chiarenza SF, Caldaro T, Cheli M, Boroni G, Marcandella ES, Riccipetitoni G, Cacciaguerra S, Di Benedetto V, Gentilino V, Lisi G, Morini F, Midrio P. Diagnosis and Management of Congenital H-Type Tracheoesophageal Fistula: Results of a National Survey. CHILDREN (BASEL, SWITZERLAND) 2024; 11:423. [PMID: 38671640 PMCID: PMC11048938 DOI: 10.3390/children11040423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/12/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Congenital h-type tracheoesophageal fistula (H-TEF) without esophageal atresia (EA) represents about 4% of congenital esophageal anomalies. The diagnosis is challenging, and surgery is considered curative. The aim was to report a national survey on the diagnosis, management, and outcome of patients with congenital H-TEF. METHODS Following approval of the Italian Society of Pediatric Surgery, a survey was sent to all Pediatric Surgery Units to retrospectively collect H-TEF treated in the period 2010-2022. Descriptive analysis was performed, and results are given as prevalence, mean ± standard deviation (SD), or median and interquartile range (IQR). RESULTS The survey was sent to 65 units. Seventeen responded with one or more cases; 78 patients were diagnosed with H-TEF during the study period. Associated malformations were present in 43%, mostly cardiac (31%). The most frequent symptoms were cough (36%), bronchopneumonia (24%), and dysphagia (19%). H-TEF was detected by tracheobronchoscopy (90%), and/or upper GI (58%), and/or esophagoscopy (32%). The median age at diagnosis was 23 days (1 day-18 years). The most common approach was cervicotomy (76%), followed by thoracoscopy (14%) and thoracotomy (9%). The fistula underwent ligation and section of the fistula in 90% of the patients and clip closure and section in 9%. In one patient, the fistula was cauterized endoscopically. H-TEF preoperative cannulation was performed in 68% of cases, and a drain was placed in 26%. One month after surgery, 13% of the patients had mild persisting symptoms, mainly hypophonia. Recurrence occurred in 5%, and a second recurrence occurred in 1%. CONCLUSIONS H-TEF prevalence was six cases/year, consistent with the expected rate of five cases/year in our country. The diagnosis was challenging, sometimes delayed, and, in most patients, required multiple examinations. Fistula ligation and section through cervicotomy were the most frequent treatment. Long-term outcomes are good, and recurrence is a rare event.
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Affiliation(s)
- Cecilia Morchio
- School of Pediatric Surgery, University of Florence, 50100 Florence, Italy;
| | - Alba Ganarin
- Pediatric Surgery Unit, Ca’ Foncello Hospital, 31100 Treviso, Italy;
| | - Andrea Conforti
- Neonatal Surgery Unit, Medical and Surgical Department of Fetus-Newborn-Infant, Bambino Gesù Children’s Hospital, IRCCS, 00100 Rome, Italy;
| | - Ernesto Leva
- Pediatric Surgery Unit, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, University of Milan, 20100 Milan, Italy;
| | - Giovanni Gaglione
- UOC Pediatric Surgery Unit, AORN Santobono-Pausilipon, 80100 Naples, Italy;
| | - Gaia Brenco
- Pediatric Surgery Unit, IRCCS Giannina Gaslini’s Hospital, 16100 Genova, Italy;
| | - Elisa Zambaiti
- Department of Pediatric General Surgery, Regina Margherita Children’s Hospital, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, 10100 Turin, Italy;
| | | | - Tamara Caldaro
- Digestive Endoscopy and Surgery Unit, Bambino Gesu Children’s Hospital, IRCCS, 00100 Rome, Italy;
| | - Maurizio Cheli
- Pediatric Surgery Unit, Ospedale Papa Giovanni XXIII, 24100 Bergamo, Italy;
| | - Giovanni Boroni
- Department of Paediatric Surgery, ASST Spedali Civili di Brescia, 25100 Brescia, Italy;
| | - Elena Sofia Marcandella
- Paediatric Surgery Unit, Women’s and Children’s Health Department, University of Padua, 35100 Padua, Italy;
| | - Giovanna Riccipetitoni
- Department of Paediatric Surgery, “V. Buzzi” Children’s Hospital, 20100 Milan, Italy;
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Vincenzo Di Benedetto
- Department of Pediatric Surgery, G. Rodolico—San Marco Hospital, 95100 Catania, Italy;
| | - Valerio Gentilino
- Division of Pediatric Surgery, Woman and Child Department, “Filippo Del Ponte” Hospital, ASST Sette Laghi, 21100 Varese, Italy;
| | - Gabriele Lisi
- Pediatric Surgery Unit, Santo Spirito Hospital, University of Chieti-Pescara, 65100 Pescara, Italy;
| | - Francesco Morini
- Department of Maternal and Child Health and Urological Sciences, La Sapienza University, 00100 Rome, Italy;
| | - Paola Midrio
- Pediatric Surgery Unit, Ca’ Foncello Hospital, 31100 Treviso, Italy;
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Więckowski PR, Łysak JM, Maciejewski IZ, Wolski M. A Cautionary Tale: Undetected H-type Tracheoesophageal Fistula in an Adolescent Male. Cureus 2024; 16:e57647. [PMID: 38707062 PMCID: PMC11070070 DOI: 10.7759/cureus.57647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2024] [Indexed: 05/07/2024] Open
Abstract
An H-type tracheoesophageal fistula is a rare congenital anomaly consisting of an abnormal passageway between the esophagus and the trachea without the presence of esophageal atresia. This condition is usually detected early in infancy; however, some patients may receive a delayed diagnosis. Symptoms experienced by people affected with an H-type tracheoesophageal fistula vary greatly and may consist of bouts of coughing when swallowing liquids and recurring lower respiratory infections. The most commonly used initial diagnostic tests can produce falsely negative results. The treatment of choice for the majority of H-type tracheoesophageal fistulas is an open surgical procedure; however, the thoracoscopic approach has proven effective in cases where the fistula is located below the thoracic outlet. In this case report, we describe a patient whose diagnosis of H-type tracheoesophageal fistula was delayed by 13 years and who was successfully treated using thoracoscopic surgery.
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Affiliation(s)
- Piotr R Więckowski
- Department of Pediatric Surgery and Organ Transplantation, Children's Memorial Health Institute, Warszawa, POL
- Department of Pediatric Surgery, Medical University of Warsaw, Warszawa, POL
| | - Joanna M Łysak
- Department of Pediatric Surgery, Medical University of Warsaw, Warszawa, POL
| | | | - Marek Wolski
- Department of Pediatric Surgery, Medical University of Warsaw, Warszawa, POL
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4
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Feng C, Li L, Zhang Y, Zhao Y, Huang J. Diagnosis and management of congenital type D esophageal atresia. Pediatr Surg Int 2023; 39:280. [PMID: 37815659 PMCID: PMC10564804 DOI: 10.1007/s00383-023-05519-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 10/11/2023]
Abstract
This study was performed to describe the current clinical practice and outcomes of type D esophageal atresia. We retrospectively analyzed 10 patients who were diagnosed with type D esophageal atresia and underwent esophageal atresia and tracheoesophageal fistula repair in the Capital Institute of Pediatrics and Beijing Children's Hospital from January 2017 to May 2022. Ten patients include three newborns and seven non-newborns. Seven (70%) cases were misdiagnosed as type C esophageal atresia before the first operation. Three neonatal children underwent thoracoscopic distal tracheoesophageal fistula ligation and esophageal anastomosis: the proximal tracheoesophageal fistula was simultaneously repaired with thoracoscopy in one of these children, and the proximal tracheoesophageal fistula was not detected under thoracoscopy in the other two children. Among the seven non-neonatal children, one underwent repair of the proximal tracheoesophageal fistula through the chest and the other six underwent repair through the neck. Nine patients were cured, and one died of complications of severe congenital heart disease. Type D esophageal atresia lacks specific clinical manifestations. Misdiagnosis as type C esophageal atresia is the main cause of an unplanned reoperation. Patients without severe malformations have a good prognosis.
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Affiliation(s)
- Cuizhu Feng
- Department of Pediatric Surgery, Capital Institution of Pediatrics, Beijing, People's Republic of China
- Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment, Chinese Academy of Medical Sciences 2021RU015, Beijing, China
| | - Long Li
- Department of Pediatric Surgery, Capital Institution of Pediatrics, Beijing, People's Republic of China
| | - Yanxia Zhang
- Department of Pediatric Surgery, Capital Institution of Pediatrics, Beijing, People's Republic of China
| | - Yong Zhao
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center of Children's Health, Beijing, People's Republic of China
| | - Jinshi Huang
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center of Children's Health, Beijing, People's Republic of China.
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Hosseini A, Sinaei R, Yeganeh MH, Boroujeni MG, Dara N, Sadr S, Iranikhah A, Rouzrokh M. A dual H-type tracheoesophageal fistula; why not being repaired simultaneously? A case report and review of literature. BMC Pediatr 2023; 23:308. [PMID: 37337161 DOI: 10.1186/s12887-023-03945-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 03/06/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND H-type Tracheoesophageal Fistula (TEF) is a particular type of congenital esophageal anomalies, in which patients present with non-specific symptoms that can result in delayed diagnosis. Here, we report two pediatric cases with a rarer variant called ‟dual H-type TEFˮ. CASE PRESENTATION We present two cases of H-type TEF. The first was a 45-day-old boy with feeding problem and cyanosis while feeding, and the second was a three-month-old girl with cough and choking after feeding from the first day of birth. In both cases, two separate TEFs were detected during diagnostic evaluation by flexible bronchoscopy. Both were repaired simultaneously through a cervical incision. The first patient deteriorated 13 days after the surgery, disturbancing in acid-base balance and expired unfortunately. CONCLUSION Hence, it is necessary to consider the possibility of double TEF in any newly diagnosed H-type TEF.
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Affiliation(s)
- Amirhossein Hosseini
- Pediatric Gastroenterology, Hepatology and Nutrition Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Sinaei
- Department of Pediatrics, School of medicine, Kerman University of Medical Sciences, Kerman, Iran.
- Clinical Research Development Unit, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran.
| | | | | | - Naghi Dara
- Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Pediatric Gastroenterology, Hepatology and Nutrition, Tehran, Iran
| | - Saeed Sadr
- Mofid Children's Hospital, Department of Pediatric Pulmonology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abolfazl Iranikhah
- Qom University of Medical Sciences, Pediatric Gastroenterology, Hepatology and Clinical Nutrition, Qom, Iran
| | - Mohsen Rouzrokh
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Pediatric Surgery, Tehran, Iran
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Thulium LASER for endoscopic closure of tracheoesophageal fistula in esophageal atresia's spectrum: An appropriate tool? J Pediatr Surg 2021; 56:1752-1756. [PMID: 33199056 DOI: 10.1016/j.jpedsurg.2020.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/28/2020] [Accepted: 10/09/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE To report our experience with endoscopic Thulium LASER for treatment of recurrent TEF after EA surgery, and for H-Type fistulas. METHODS A retrospective chart review of consecutive patients undergoing standardized endoscopic closure as first line therapy of recurrent tracheoesophageal fistula (RTEF) and H-type fistula using Thulium LASER, from 2013 to 2019, in a pediatric tertiary care center. Control endoscopic procedure was systematically performed. If persistence of the TEF was noted an external approach was performed. Patient demographics, medical history, symptoms, TEF type, treatment modalities, complications and outcomes were collected. RESULTS Eleven patients with tracheoesophageal fistula were included: six RTEF after primary repair of esophageal atresia and five H-type fistulas. The average age at endoscopic treatment was 19 months (SD 23 months, range 13 days-63 months). Closure of the fistula after single endoscopic procedure with Thulium LASER was obtained in 3 RTEF (50%) and 1 H-type fistula (20%). Six patients with failure of endoscopic treatment were cured after a single external procedure without any complications. One child, treated for H-type fistula, presented a severe complication of Thulium LASER treatment. Median follow-up after last repair was 24 months (range: 14-72 months). All fistulas were successfully treated. CONCLUSIONS In H-Type fistula, success rate of Thulium LASER is only 20% and thus should not be used. In contrast, in RTEF, success rate of 50% is achieved, avoiding as many open procedures, and Thulium LASER could be considered as first line treatment. In any case, open surgery is safe and efficient and can be considered as a first-line treatment for H-type fistulas, and as a salvage treatment for endoscopic treatment failures. LEVELS OF EVIDENCE Level IV.
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7
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Thoracoscopic repair of congenital isolated H-type tracheoesophageal fistula. J Pediatr Surg 2021; 56:1386-1388. [PMID: 32972739 DOI: 10.1016/j.jpedsurg.2020.08.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/28/2020] [Accepted: 08/19/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND/PURPOSE The available literature on congenital isolated H-type tracheoesophageal fistula (TEF) is limited, and preferred approach varies among centers (cervicotomy, thoracotomy, thoracoscopy). We aimed to present one of the biggest case series of thoracoscopic approach for congenital isolated TEF and to assess the method's feasibility and outcomes. METHODS Retrospective review of thoracoscopic TEF repair experiences at 2 European university pediatric surgery centers. RESULTS 9 boys and 3 girls were involved in the study (age 5 days-4 years), 8 of them were newborns (mean birth weight 3013 g, mean gestational age 39 weeks). The most common presenting symptoms were desaturations on feeding in neonates and recurrent respiratory tract infections in older children. The diagnoses were established on contrast study and confirmed with rigid bronchoscopy. The fistulas were located at or below the thoracic inlet; the fistulas were 2 cm above the carina to half the height of the trachea. All patients underwent successful thoracoscopic TEF repair. There were no conversions. The postoperative course was uneventful in all but one who had rethoracoscopy for prolonged postoperative chylothorax. All patients had satisfactory vocal cord function. One patient required reoperation for fistula recurrence 8 months after primary surgery. CONCLUSION Thoracoscopic approach for isolated H-type TEF seems to be possible as a procedure of choice with satisfactory results and all benefits of minimally invasive procedure. LEVEL OF EVIDENCE IV (case series).
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8
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Congenital H-Fistula without Oesophageal Atresia- point of technique. Asian J Surg 2021; 44:1197-1198. [PMID: 34148747 DOI: 10.1016/j.asjsur.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/01/2021] [Indexed: 11/23/2022] Open
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9
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Chebib E, Van Den Abbeele T, Benoit C. Closure of a tracheo-esophageal fistula using a 3D-exoscopic visualization in a newborn (with video). Eur Ann Otorhinolaryngol Head Neck Dis 2021; 138 Suppl 1:10-11. [PMID: 34127412 DOI: 10.1016/j.anorl.2021.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/19/2021] [Accepted: 01/25/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Emilien Chebib
- Department of Otolaryngology, Robert Debre Hospital, Assistance Publique Hôpitaux de Paris (APHP) and Paris university, 48, boulevard Sérurier, 75019 Paris, France.
| | - Thierry Van Den Abbeele
- Department of Otolaryngology, Robert Debre Hospital, Assistance Publique Hôpitaux de Paris (APHP) and Paris university, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, U1141, NeuroDiderot, Inserm, 75019 Paris, France
| | - Charlotte Benoit
- Department of Otolaryngology, Robert Debre Hospital, Assistance Publique Hôpitaux de Paris (APHP) and Paris university, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, U1141, NeuroDiderot, Inserm, 75019 Paris, France
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Gutierrez RS, Guelfand M, Balbontin PV. Congenital and acquired tracheoesophageal fistulas in children. Semin Pediatr Surg 2021; 30:151060. [PMID: 34172208 DOI: 10.1016/j.sempedsurg.2021.151060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Tracheoesophageal fistulas (TEF) are an anomalous communication between airway and esophagus. There are several types of TEF. Congenital are mainly associated to an esophageal atresia. The type III or C, in which the upper segment of the esophagus ends in a blind pouch and there is distal tracheoesophageal fistula above the carina, accounts for 85% of esophageal atresias. The other are extremely infrequent. H-type or N-type TEF, classified as type 5 or E, is an uncommon variant and accounts for less than 4%. Recurrent TEF is a serious complication after first surgery of esophageal atresia and TEF. The rate of recurrence of TEF is estimated between 3-15%. The treatment is a challenge with a high rate of recurrence after surgery. Classical symptoms of RTEF include coughing especially after drinking, abdominal distension, repeated cyanosis, and respiratory infections. In the case of H-type fistula the symptoms are similar but appear during the first month of life. In this chapter we presented the management and alternative treatments of the congenital and acquired TEF.
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Affiliation(s)
- Rocío S Gutierrez
- Department of Pediatric Surgery and Urology, University Hospital Arnau de Vilanova, Lleida, Spain.
| | - Miguel Guelfand
- Division of Pediatric Surgery, Exequiel Gonzalez Cortes Children´s Hospital, Clinica Las Condes Medical Center, Santiago, Chile
| | - Patricio Varela Balbontin
- Division of Pediatric Surgery, Luis Calvo Mackenna Children´s Hospital, University of Chile, Clinica Las Condes Medical Center, Santiago, Chile
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Sampat K, Losty PD. Diagnostic and management strategies for congenital H-type tracheoesophageal fistula: a systematic review. Pediatr Surg Int 2021; 37:539-547. [PMID: 33474597 PMCID: PMC8026411 DOI: 10.1007/s00383-020-04853-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND H type tracheoesophageal fistula (H-TEF) is a rare congenital anomaly. Management may be complicated by late diagnosis and variation(s) in the therapeutic strategy. A systematic review of published studies explores the utility of diagnostic studies, operations and postoperative complications. METHODS Medline and PubMed database(s) were searched for ALL studies reporting H-TEF during 1997-2020. Using PRISMA methodology, manuscripts were screened for eligibility and reporting. RESULTS Forty-seven eligible studies were analysed. Primary diagnosis varied widely with surgeons performing oesophagography and trachea-bronchoscopy. Preoperative localisation techniques included fluoroscopy, guidewire placement and catheterisation. A cervical approach (209 of 272 cases), as well as thoracotomy, thoracoscopy and endoscopic fistula ligation, were all described. Morbidity included fistula recurrence (1.7%), leak (2%), tracheomalacia (3.4%) and respiratory sequelae (1%). The major adverse complication in all studies was vocal cord palsy secondary to laryngeal nerve injury (18.5%) yet strikingly few centres routinely reported undertaking vocal cord screening pre or postoperatively. CONCLUSION This study shows that paediatric surgeons record low volume activity with H type tracheoesophageal fistula. Variation(s) in clinical practice are widely evident. Laryngeal nerve injury and its subsequent management warrant special consideration. Care pathways may offset attendant morbidity and define 'best practice.'
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Affiliation(s)
- Keerthika Sampat
- Department of Paediatric Surgery, Alder Hey Childrens’ Hospital, Liverpool, UK
| | - Paul D. Losty
- Department of Paediatric Surgery, Alder Hey Childrens’ Hospital, Liverpool, UK ,Institute of Child Health, School of Health And Life Science, University of Liverpool, Liverpool, UK
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12
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H-type congenital tracheoesophageal fistula: Insights from 70 years of The Royal Children's Hospital experience. J Pediatr Surg 2021; 56:686-691. [PMID: 32807528 DOI: 10.1016/j.jpedsurg.2020.06.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/17/2020] [Accepted: 06/30/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND The long-term outcomes of H-type tracheoesophageal fistula (TOF), an uncommon variant of esophageal atresia/tracheoesophageal fistula (OA/TOF), are rarely described in the literature. We reviewed our institutional experience of 70 years. METHODS The Nate Myers Oesophageal Atresia Database was queried for patients with an H-type TOF (1948-2017). Data included presentation, diagnostic workup, surgical management, and outcomes. RESULTS Of 1088 patients with OA/TOF, 56 (5.1%) had an H-type TOF. The most common presenting symptoms were cyanotic episodes (68%), choking with feeds (52%), and aspiration pneumonitis (46%). The majority (82%) were symptomatic in the first week of life. Coexisting congenital anomalies were present in 46%: cardiac (13/56, 23%), genitourinary (10/56, 18%), and vertebral/skeletal (9/56, 16%). Patients were consistently diagnosed with prone contrast tube esophagogram (77% sensitivity on the first study and 96% after a second study). The fistula was most commonly approached through a right cervical collar incision. Right vocal cord palsy occurred in 22%, with one case of bilateral palsies. Other complications included leak (5.6%), recurrence (9.3%), stricture (1.9%), and diverticulum (1.9%). Although there was a trend towards a lower recurrence rate when interposition material was used, this was not statistically significant (3.3% vs 16.7%, p = 0.16). Survival in operative cases was 98.2%, and when all diagnosed cases were considered was 89.3%. CONCLUSIONS We have reported the largest single-center series of H-type TOF. Diagnosis is challenging, and surgical morbidity remains high. Despite this, long-term outcomes are favorable. LEVEL OF EVIDENCE IV.
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13
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Spataru RI, Iozsa DA, Lupusoru MOD, Serban D, Cirstoveanu C. Practical safety in the diagnosis and treatment of congenital isolated tracheoesophageal fistula. Exp Ther Med 2021; 21:537. [PMID: 33815610 DOI: 10.3892/etm.2021.9970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 02/22/2021] [Indexed: 11/05/2022] Open
Abstract
The rareness of H-type tracheoesophageal fistula in conjunction with its unspecific clinical presentation and wide range of anatomical presentation makes its diagnosis and treatment a problematic topic for both ear, nose and throat (ENT) specialists and pediatric surgeons worldwide. Symptoms and clinical signs of H-TOF are easily misleading. Diagnostic methods, most of the times, are dependent on the physician's experience; therefore, various errors may be made. We analyzed our experience in managing H-TOF cases over the last 15 years. Advice and strategies of action for health professionals directly involved in the diagnosis and treatment were identified, but also errors and mistakes while managing 6 cases. We analyzed 'red flags' but also important steps in the practical safety concerning this rare congenital malformation. Choosing the surgical access for division of the fistula throughout the cervical or thoracic approach is sometimes difficult. A scrupulous perioperative planning is mandatory. A dynamic overview of the patient's presentation never underestimating the subtlety of H-TOF presentation should be conducted for its early recognition and achieving best outcomes.
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Affiliation(s)
- Radu-Iulian Spataru
- Discipline of Pediatric Surgery, Department of Plastic and Reconstructive Surgery and Pediatric Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Pediatric Surgery, Emergency Clinical Hospital for Children 'Maria Sklodowska Curie', 41451 Bucharest, Romania
| | - Dan-Alexandru Iozsa
- Discipline of Pediatric Surgery, Department of Plastic and Reconstructive Surgery and Pediatric Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Pediatric Surgery, Emergency Clinical Hospital for Children 'Maria Sklodowska Curie', 41451 Bucharest, Romania
| | - Mircea Ovidiu Denis Lupusoru
- Discipline of Physiology, Department 2, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Dragos Serban
- Discipline of General Surgery, Department of General Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of General Surgery, Emergency University Hospital, 050098 Bucharest, Romania
| | - Catalin Cirstoveanu
- Discipline of Pediatrics, Department of Pediatrics, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Neonatal Intensive Care Unit, 'Marie S. Curie' Emergency Clinic Hospital for Children, 41451 Bucharest, Romania
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14
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Kaufmann J, Laschat M, Schieren M, Böckenholt K, Klein T, Wappler F. Hypopharyngeal Perforation Mimicking Esophageal Atresia: A Case Report of an Extremely Low Birth Weight Infant Emphasizing the Need for Preoperative Endoscopy. A A Pract 2021; 15:e01414. [PMID: 33684085 DOI: 10.1213/xaa.0000000000001414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of an extremely low birth weight premature infant born at 27 weeks of gestation, transferred to our tertiary pediatric referral center for surgical repair of an esophageal atresia. Endoscopic evaluation before the start of surgery revealed a hypopharyngeal perforation, resulting in the false impression of esophageal atresia. If no tracheoesophageal fistula is found during tracheoscopy, esophagoscopy should be done before surgical intervention as the inability to pass a nasogastric tube into the stomach is not sufficiently reliable for a correct diagnosis of esophageal atresia.
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Affiliation(s)
- Jost Kaufmann
- From the Department for Pediatric Anesthesia and Endoscopy, Children's Hospital, Cologne, Germany.,Faculty of Health, University of Witten/Herdecke, Witten, Germany
| | - Michael Laschat
- From the Department for Pediatric Anesthesia and Endoscopy, Children's Hospital, Cologne, Germany
| | - Mark Schieren
- From the Department for Pediatric Anesthesia and Endoscopy, Children's Hospital, Cologne, Germany.,Faculty of Health, University of Witten/Herdecke, Witten, Germany
| | - Kai Böckenholt
- Clinic for Pediatrics, Department for Neonatal Intensive Care, Children's Hospital, Cologne, Germany, Children's Hospital, Cologne, Germany
| | - Tobias Klein
- Clinic for Pediatric Surgery and Urology, Children's Hospital, Cologne, Germany
| | - Frank Wappler
- From the Department for Pediatric Anesthesia and Endoscopy, Children's Hospital, Cologne, Germany.,Faculty of Health, University of Witten/Herdecke, Witten, Germany
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15
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Quick ME, Giblett N, Uwiera TC, Herbert H, Vijayasekaran S. A novel approach in managing challenging tracheoesophageal fistulae. Int J Pediatr Otorhinolaryngol 2020; 138:110261. [PMID: 32798829 DOI: 10.1016/j.ijporl.2020.110261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To analyze the outcomes of an open anterior cervical approach and tospecifically describe a novel extended tracheotomy incision ("Key-hole technique") torepair H-type and other challenging tracheoesophageal fistulae (TOF) at a singletertiary pediatric center. METHOD A retrospective chart analysis of pediatric patients (0-18 years old) who had undergone repair of TOF's between January 2006 and March 2020 were reviewed. A case series of patients who had undergone open cervical utilizing three different techniques were included. Patient demographics, surgical management and post-operative surgical outcomes including complications were evaluated. RESULTS During the study period, 117 pediatric patients were diagnosed and anaged with TOFs with or without oesophageal atresia. Within this group, 12 patients (10%) had anterior open cervical repair of congenital or persisting TOFs (6 males and 6 females). Eight cases (7%) had congenital Type E (known as H-type), two had type D, one type B and one type C TOF. Median gestational age was 37 weeks (range 28-41 weeks), age of presentation ranged from 1 day old to 3 years old with 67% being diagnosed within the first month of life. At the time of definitive surgery all patients had a bronchoscopy and oesophagoscopy to confirm the diagnosis, identify the level of the fistula and place a catheter through the fistula. This cases series of open anterior cervical repair of TOFs comprised of seven (58%) patients who had primary extraluminal tracheal approach, four (33%) with extended tracheotomy incision ('Key-hole' technique) and one (9%) patient with slide tracheoplasty for recurrent type C TOF in the presence of subglottic stenosis. Eleven of the twelve patients had successful open anterior cervical repair of TOF. One patient who had primary open anterior cervical repair with the 'Key-hole' technique had recurrence managed successfully with slide tracheoplasty. There were no cases of recurrent laryngeal nerve injury. CONCLUSION This series demonstrates that open anterior cervical approach to correct TOFs is an effective and safe method in the majority of cases of congenital and acquired fistulae where there is no oesophageal atresia or the atresia is corrected (in the case of recurrent or second fistulae). We also present the outcomes of a novel surgical "Keyhole" technique to manage TOF fistulas via an extended-tracheotomy incision. We also found that slide tracheoplasty is an effective salvage operation in the case of complex recurrent fistulae.
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Affiliation(s)
- Mark E Quick
- Department of Otolaryngology, Perth Children's Hospital, Nedlands, WA, Australia.
| | - Neil Giblett
- Department of Otolaryngology, Perth Children's Hospital, Nedlands, WA, Australia
| | - Trina C Uwiera
- Division of Pediatric Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Hayley Herbert
- Department of Otolaryngology, Perth Children's Hospital, Nedlands, WA, Australia
| | - Shyan Vijayasekaran
- Department of Otolaryngology, Perth Children's Hospital, Nedlands, WA, Australia; Faculty of Health and Medical Sciences, University of Western Australia, WA, Australia
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Thoracoscopy vs. thoracotomy for the repair of esophageal atresia and tracheoesophageal fistula: a systematic review and meta-analysis. Pediatr Surg Int 2019; 35:1167-1184. [PMID: 31359222 DOI: 10.1007/s00383-019-04527-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2019] [Indexed: 12/14/2022]
Abstract
Esophageal atresia (EA) and tracheoesophageal fistula (TEF) require emergency surgery in the neonatal period to prevent aspiration and respiratory compromise. Surgery was once exclusively performed via thoracotomy; however, there has been a push to correct this anomaly thoracoscopically. In this study, we compare intra- and post-operative outcomes of both techniques. A systematic review and meta-analyses was performed. A search strategy was developed in consultation with a librarian which was executed in CENTRAL, MEDLINE, and EMBASE from inception until January 2017. Two independent researchers screened eligible articles at title and abstract level. Full texts of potentially relevant articles were then screened again. Relevant data were extracted and analyzed. 48 articles were included. A meta-analysis found no statistically significant difference between thoracoscopy and thoracotomy in our primary outcome of total complication rate (OR 0.98, [0.29, 3.24], p = 0.97). Likewise, there were no statistically significant differences in anastomotic leak rates (OR 1.55, [0.72, 3.34], p = 0.26), formation of esophageal strictures following anastomoses that required one or more dilations (OR 1.92, [0.93, 3.98], p = 0.08), need for fundoplication following EA repair (OR 1.22, [0.39, 3.75], p = 0.73)-with the exception of operative time (MD 30.68, [4.35, 57.01], p = 0.02). Considering results from thoracoscopy alone, overall mortality in patients was low at 3.2% and in most cases was due to an associated anomaly rather than EA repair. Repair of EA/TEF is safe, with no statistically significant differences in morbidity when compared with an open approach.Level of evidence 3a systematic review of case-control studies.
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17
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Dai J, Pan Z, Wang Q, Wu Y, Wang J, Wang G, Wu C, Wang Y. Experience of diagnosis and treatment of 31 H-type tracheoesophageal fistula in a single clinical center. Pediatr Surg Int 2018; 34:715-719. [PMID: 29855692 DOI: 10.1007/s00383-018-4293-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/29/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To summarize the experience of the diagnosis and treatment of 31 H-type tracheoesophageal fistula (TEF) at the Children's Hospital of Chongqing Medical University, Chongqing, China. METHODS A total of 31 patients with H-type TEF were enrolled in this retrospective study from January 2000 to July 2017, and the diagnosis and treatment of the disease were analyzed and summarized. RESULTS Iodine oil examination of the esophagus, fiberoptic bronchoscopy combined with esophagoscopy and three-dimensional computed tomography (3-D CT) reconstruction of the trachea and esophagus was used separately in 31 patients. 1 patient who had his TEF ligatured directly experienced recurrence 1 month after surgery, but recovered after TEF suturing. Subsequently, the remaining 30 patients were treated by suturing after TEF excision. All patients were followed up for 3 months-2 years and did not suffer from anastomosis orifice stenosis, gastroesophageal reflux, and a recurrent respiratory tract infection. Three patients exhibited vocal cord paralysis and improved spontaneously after a follow-up of 3-6 months. CONCLUSION H-type TEF is diagnosed by iodine oil examination of the esophagus, fiberoptic bronchoscopy combined with esophagoscopy, and 3-D CT reconstruction of the trachea and esophagus. Excision and suturing of the TEF separately are an effective treatment for the disease and are an excellent outcome.
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Affiliation(s)
- Jiangtao Dai
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China.,Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People's Republic of China
| | - Zhengxia Pan
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Quan Wang
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Yuhao Wu
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Junke Wang
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Gang Wang
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Chun Wu
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China.
| | - Yi Wang
- Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China.
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AlHindi S, AlDulaijan R. WITHDRAWN: Thoracic H-type Tracheoesophageal fistula after repair of anorectal malformation in neonate. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2018.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Cullis PS, Gudlaugsdottir K, Andrews J. A systematic review of the quality of conduct and reporting of systematic reviews and meta-analyses in paediatric surgery. PLoS One 2017; 12:e0175213. [PMID: 28384296 PMCID: PMC5383307 DOI: 10.1371/journal.pone.0175213] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 03/22/2017] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Our objective was to evaluate quality of conduct and reporting of published systematic reviews and meta-analyses in paediatric surgery. We also aimed to identify characteristics predictive of review quality. BACKGROUND Systematic reviews summarise evidence by combining sources, but are potentially prone to bias. To counter this, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was published to aid in reporting. Similarly, the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) measurement tool was designed to appraise methodology. The paediatric surgical literature has seen an increasing number of reviews over the past decade, but quality has not been evaluated. METHODS Adhering to PRISMA guidelines, we performed a systematic review with a priori design to identify systematic reviews and meta-analyses of interventions in paediatric surgery. From 01/2010 to 06/2016, we searched: MEDLINE, EMBASE, Cochrane, Centre for Reviews and Dissemination, Web of Science, Google Scholar, reference lists and journals. Two reviewers independently selected studies and extracted data. We assessed conduct and reporting using AMSTAR and PRISMA. Scores were calculated as the sum of reported items. We also extracted author, journal and article characteristics, and used them in exploratory analysis to determine which variables predict quality. RESULTS 112 articles fulfilled eligibility criteria (53 systematic reviews; 59 meta-analyses). Overall, 68% AMSTAR and 56.8% PRISMA items were reported adequately. Poorest scores were identified with regards a priori design, inclusion of structured summaries, including the grey literature, citing excluded articles and evaluating bias. 13 reviews were pre-registered and 6 in PRISMA-endorsing journals. The following predicted quality in univariate analysis:, word count, Cochrane review, journal h-index, impact factor, journal endorses PRISMA, PRISMA adherence suggested in author guidance, article mentions PRISMA, review includes comparison of interventions and review registration. The latter three variables were significant in multivariate regression. CONCLUSIONS There are gaps in the conduct and reporting of systematic reviews in paediatric surgery. More endorsement by journals of the PRISMA guideline may improve review quality, and the dissemination of reliable evidence to paediatric clinicians.
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Affiliation(s)
- Paul Stephen Cullis
- Department of Surgical Paediatrics, Royal Hospital for Children, Glasgow, United Kingdom
- School of Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Katrin Gudlaugsdottir
- Department of Surgical Paediatrics, Royal Hospital for Children, Glasgow, United Kingdom
| | - James Andrews
- Department of Surgical Paediatrics, Royal Hospital for Children, Glasgow, United Kingdom
- School of Medicine, University of Glasgow, Glasgow, United Kingdom
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Abstract
PURPOSE To evaluate outcomes following repair of H-type tracheoesophageal fistula (TEF). METHODS Retrospective chart review of infants with H-type TEF treated at our institution between 2000 and 2014. Patient demographics, surgical management, and postoperative function were evaluated. RESULTS Of the 268 patients with esophageal atresia/TEF treated at our center, 16 (6%) had an H-type TEF (10 males). Thirteen (81%) had associated anomalies. All patients were symptomatic: choking and sputtering were the most common presentation (n = 10, 63%). Diagnosis Age at diagnosis was 8 days (1 day-34 months). All patients were diagnosed based on a single esophagogram. Prior to surgery, 12 (75%) patients underwent bronchoscopy and 11 underwent cannulation of the TEF tract. Surgery All patients underwent open repair. One was started thoracoscopically but converted to open due to esophageal sero-muscular injury. Repair was achieved in all patients via a transcervical approach (right-sided incision in 15). One patient had an unsuccessful prior attempt at repair using tissue glue. Following TEF division, 11 patients had tissue interposition grafts placed (9 muscle, 2 fat). Postoperative course Eight (50%) patients had postoperative vocal cord paresis (6 right-sided, 2 bilateral). A patient developed recurrent TEF 78 days postoperatively that was subsequently repaired. Follow-up At 41 months (8-143), there were no mortalities, all patients with vocal cord paresis were asymptomatic despite the fact that only 3 of 8 (38%) regained function, and nine (56%) patients had gastro-esophageal reflux requiring treatment. CONCLUSIONS This large, single-center series demonstrates that H-type TEF can be diagnosed with esophagogram at an early age. Postoperative recurrent laryngeal nerve paresis and gastro-esophageal reflux disease are common following repair. Although most patients with vocal cord paresis eventually become asymptomatic, two-thirds do not regain vocal cord function. This reinforces the importance of routine examination of vocal cord movement following H-type TEF repair.
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Cervical repair of congenital tracheoesophageal fistula: Complications lurking! J Pediatr Surg 2016; 51:1623-6. [PMID: 27372236 DOI: 10.1016/j.jpedsurg.2016.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 06/01/2016] [Accepted: 06/09/2016] [Indexed: 12/17/2022]
Abstract
AIM Esophageal atresia (EA) and tracheoesophageal fistula (TEF) consist of a spectrum of rare congenital abnormalities. Although EA surgical treatment is well established, the outcome of EA with proximal fistula (type B and D EA) or isolated H-type fistula (type E EA) is poorly explored. These forms of EA shared a common surgical step: the need of a cervical approach to close the fistula. Therefore, the aim of present study is to evaluate postoperative outcomes of patients treated for Gross type B-D and E EA, on regards of their cervical surgery. MATERIALS AND METHODS A retrospective case series analysis of all patients affected by type B-D and E EA, and admitted to our tertiary care center between January 2003 and December 2014 was performed. All patients underwent preoperative flexible laryngo-tracheobronchoscopy (LTBS) as part of our standardized preoperative diagnostic assessment to define the diagnosis, evaluate preoperative vocal cord motility and to cannulate the fistula when required. Fistula closure was always performed through a right cervical access. Analysis of all cases and comparison between type B-D and E EA were performed. Mann-Whitney test, Chi-squared test and unpaired t test were used as appropriate; p<0.05 was considered significant. RESULTS During the study period, 180 EA newborns were treated. Proximal or isolated TEF was found in 18 patients (10%): 7 type B, 11 type E EA. Patients affected by type B and E EA/TEF frequently present associated major malformations (27%), and major cardiac abnormalities (44%). Major postoperative complications were: vocal cord paralysis (5 patients), bilateral in 2 infants requiring tracheostomy, cerebral ischemia (1 patient), and cardiac failure (1 patient). CONCLUSION Patients affected by type B and E EA have a high rate of associated abnormalities, and risk of possible sequelae. Postoperative complications are common, with possible transient vocal cord dismotility, but in some cases persistent paralysis may require tracheostomy. Therefore, both preoperative and postoperative LTBS is highly recommended to evaluate the presence of a proximal fistula, and vocal cord motility, even in asymptomatic patients, to rule out any possible intraoperative "surprise" and any vocal cord abnormality and to possibly define its pathogenesis (congenital vs. iatrogenic).
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Donnelly P, McVea S, Flannigan C, Bali S. Incidental diagnosis of an H-type tracheo-oesophageal fistula. BMJ Case Rep 2016; 2016:bcr-2016-215419. [PMID: 27358097 DOI: 10.1136/bcr-2016-215419] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 6-day-old term neonate who was intubated on day 1 of life for apnoeic episodes, was transferred to the regional paediatric intensive care unit (PICU) for specialist opinion following 3 failed extubations in the neonatal unit. Escherichia coli congenital pneumonia was diagnosed and the child discharged to the local hospital. Chest radiographs and inflammatory markers were in keeping with infection. However, ongoing difficulties with secretions necessitated readmission to the PICU, following a significant cyanotic episode associated with coughing. On arrival at the PICU, a large leak around the endotracheal tube (ETT) was noted. On direct laryngoscopy, the ETT was found correctly positioned, through the cords, but air was noted to be coming back from the oesophagus. Advancing the ETT towards the carina terminated the leak and raised the suspicion of a tracheo-oesophageal fistula. An H-type tracheo-oesophageal fistula was confirmed on bronchoscopy. An uneventful fistula repair was performed and the baby discharged from the PICU on day 23 of life.
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Affiliation(s)
- Peter Donnelly
- Department of Paediatric Intensive Care Unit, The Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Steven McVea
- Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Christopher Flannigan
- Department of Paediatric Intensive Care Unit, The Royal Belfast Hospital for Sick Children, Belfast, UK
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Abstract
BACKGROUND Congenital H-type tracheoesophageal fistula (TEF) is very rare and represents <5 % of all congenital tracheoesophageal malformations. This is a national, multicenter review of our experience with isolated H-type TEF outlining clinical presentation, methods of diagnosis, associated anomalies, treatment and outcome PATIENTS AND METHODS The medical records of all patients with the diagnosis of congenital H-type TEF treated at four pediatric surgery units in Saudi Arabia were retrospectively reviewed for: age at diagnosis, sex, presenting symptoms, associated anomalies, method of diagnosis, treatment and outcome. RESULTS During the study period (January 1998-December 2013), 435 infants and children with the diagnosis of esophageal atresia with or without TEF were treated. Among these, 23 (5.3 %) had isolated TEF. There were 11 males and 12 females. Their age at presentation ranged from 5 days to 3 years and 7 months but the majority (90 %) were diagnosed during their first year of life. Their clinical presentation included: chocking and coughing during feeds in 12 (52.2 %), recurrent chest infection in 16 (69.6 %) and cyanosis in 10 (43.5 %). One presented with abdominal distension also. The diagnosis was made using esophagogram. In 11 (47.8 %), a single study confirmed the diagnosis, 8 (34.8 %) required two studies while 4 (17.4 %) required three studies. Nineteen (82.6 %) had preoperative bronchoscopy and in 13 (56.5 %), a catheter was used to cannulate the fistula. All were operated through a right cervical incision except one who underwent thoracoscopic ligation and division of the fistula. In one, the fistula was only transfixed and tied without being divided. This patient developed a recurrent fistula. Two patients developed postoperative stridor secondary to recurrent laryngeal nerve palsy. In both of them, there was complete recovery. CONCLUSIONS H-type TEF is very rare and commonly presents with recurrent chest infection, chocking and coughing during feeds and cyanosis. Physicians caring for these patients should be aware of this and a high index of suspicion is of paramount importance to avoid delay in diagnosis with its associated morbidity. A contrast esophagogram is valuable in confirming the diagnosis. The study however may need to be repeated. Preoperative bronchoscopy is valuable to localize and cannulate the fistula for easier access during surgery. Surgical repair is the treatment of choice and this should be performed through a right cervical incision or thoracotomy for low fistulae. Thoracoscopic ligation and division of a low H-type fistula is an alternative and less invasive approach when compared to thoracotomy.
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