An extremely rare abnormality of a double tracheoesophageal fistula without atresia of the esophagus; a case report and review of the literature

H-type congenital tracheoesophageal fistula: Insights from 70 years of The Royal Children's Hospital experience

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.

Double H-type tracheoesophageal fistulas identified and repaired in 1 operation

Isolated tracheoesophageal ("H-type") fistula is a relatively uncommon congenital anomaly that can be difficult to identify and, at times, challenging to repair. We present a very unusual case of an infant with 2 distinct H-type tracheoesophageal fistulas (TEFs) identified and repaired in 1 operation. A newborn male infant presented with coughing with feeds. Contrast esophagram demonstrated an intrathoracic H-type fistula without esophageal atresia. In the operating room, rigid bronchoscopy was performed, and a second TEF was identified in the cervical region. A separate balloon catheter was placed in each fistula. The intrathoracic fistula was repaired through a thoracotomy incision, and the more proximal fistula was repaired through a cervical incision. Each repair was uncomplicated, and recovery was uneventful. Double H-type tracheoesophageal appears to be extremely rare. This case underscores the importance of searching for a second fistula by bronchoscopy before undertaking definitive repair of a TEF.