Recurrent tracheo-oesophageal fistula: experience with 24 patients

The largest report on thoracoscopic surgery for recurrent tracheoesophageal fistula after esophageal atresia repair

BACKGROUND

Although thoracoscopic surgery has become the routine surgical method for esophageal atresia/tracheoesophageal fistula (EA/TEF), thoracoscopic treatment for recurrent tracheoesophageal fistula (rTEF) is far from popularized.

OBJECTIVES

We aimed to explore the safety and efficacy of thoracoscopic treatment for rTEF with a large-cohort study.

METHODS

We retrospectively analyzed the clinical characteristics and outcomes of 103 consecutive patients who underwent thoracoscopic surgery for rTEF by one surgeon after EA/TEF repair at two different institutions in China from 2014 to 2021.

RESULTS

One hundred and three pediatric patients (67 boys) were enrolled and the primary operations were performed via thoracoscopic (n = 75, 72.82%) or open surgery (n = 28, 27.18%). The median age at rTEF diagnosis was 5 (3, 10) months after the primary repair. Patients were diagnosed with recurrent fistula to the trachea (n = 97, 94.17%), bronchi (n = 4, 3.88%), and lung parenchyma (n = 2, 1.94%), and all of them underwent thoracoscopic surgery at a median age of 7 (5, 14) months with a median weight of 6200 (4870, 7650) g. After the repair of rTEF, the incidence of esophageal leakage, esophageal stricture, and TEF recurrence were 12.8%, 33.4%, and 10.8%, respectively. After the follow-up, 87 patients survived, 6 died, and 10 were lost to follow-up.

CONCLUSIONS

The results of thoracoscopic surgery for rTEF were comparable with previously reported thoracotomy surgery. Owing to the clear field during the operation, rapid patient recovery and esthetic results, the thoracoscopic approach could be a better choice for experienced pediatric surgeons.

LEVEL OF EVIDENCE

LEVEL IV.

The multidisciplinary management of recurrent tracheoesophageal fistula after esophageal atresia: Experience with 135 cases from a tertiary center

BACKGROUND & AIMS

Recurrent tracheoesophageal fistula (rTEF) after esophageal atresia requires complex management across different specialties. This study reviews our experience and discusses a multidisciplinary (MDT) approach adopted in the past 4 years.

METHODS

We reviewed the medical records of 100 patients with rTEF managed by an MDT approach (post-MDT group) from 2016 to 2019. These cases were compared to a historical group of 35 patients with rTEF from 2012 to 2015 (pre-MDT group).

RESULTS

Of the 135 patients with rTEF, 124 were referred from other hospitals. Preoperative examination found tracheomalacia in 23 patients, vocal fold immobility in 19 patients, and laryngomalacia in five patients. The incidence of postoperative anastomotic leak, anastomotic stricture, and repeat recurrences was 28.1%, 23.0%, and 8.9%, respectively. The overall mortality rate was 4.4%. No statistical difference in postoperative complications was noted between the two groups. The duration of stay in the pediatric intensive care unit (P = 0.038), the duration of intubation (P = 0.049), the postoperative hospital stay (P = 0.011), and the total length of hospital stay (P = 0.001) were significantly lower in the post-MDT group. Mid-term follow-up showed 23 patients had pathological gastroesophageal reflux. Five of them underwent fundoplication and recovered.

CONCLUSION

The MDT approach by fostering coordination of surgical, medical, radiological, and nutritional management is beneficial in the management of rTEF and leads to a satisfactory outcome .

Acquired Tracheoesophageal Fistula After Esophageal Atresia Repair

Background:

Recurrence of tracheoesophageal fistula is a frequent complication after esophageal atresia repair. Acquired tracheoesophageal fistulas are long new fistulas that are localized at sites that are not typical of the congenital tracheoesophageal fistula. We present four cases to discuss the diagnostic and management challenges concerning various acquired tracheoesophageal fistula localizations.

Case Report:

We retrospectively evaluated the medical records of patients admitted with acquired tracheoesophageal fistula in the last 5 years. Among the 16 postoperative tracheoesophageal fistulas, 4 were classified as acquired tracheoesophageal fistula. Patients’ admission age ranged from 1 to 8 years. The female to male ratio was 2:2. The presented cases were admitted with recurrent respiratory tract infections, choking, and coughing. The acquired tracheoesophageal fistulas were observed between the esophagus and cervical trachea, between the esophagus and the right bronchus passing through intrathoracic abscess cavity, in the right bronchus, and between the colon conduit and trachea. One of the acquired tracheoesophageal fistulas healed spontaneously, whereas others required surgical ligation.

Conclusion:

Acquired tracheoesophageal fistula most often occurs secondary to local or diffuse mediastinitis. Acquired tracheoesophageal fistula may appear at unusual sites not typical of congenital tracheoesophageal fistula, such as esophagus-to-right bronchus and conduit to trachea. Therefore, the unusual locations of acquired tracheoesophageal fistula should be borne in mind, and patients evaluated and managed more comprehensively.

Oesophageal atresia

Oesophageal atresia (EA) is a congenital abnormality of the oesophagus that is caused by incomplete embryonic compartmentalization of the foregut. EA commonly occurs with a tracheo-oesophageal fistula (TEF). Associated birth defects or anomalies, such as VACTERL association, trisomy 18 or 21 and CHARGE syndrome, occur in the majority of patients born with EA. Although several studies have revealed signalling pathways and genes potentially involved in the development of EA, our understanding of the pathophysiology of EA lags behind the improvements in surgical and clinical care of patients born with this anomaly. EA is treated surgically to restore the oesophageal interruption and, if present, ligate and divide the TEF. Survival is now ~90% in those born with EA with severe associated anomalies and even higher in those born with EA alone. Despite these achievements, long-term gastrointestinal and respiratory complications and comorbidities in patients born with EA are common and lead to decreased quality of life. Oesophageal motility disorders are probably ubiquitous in patients after undergoing EA repair and often underlie these complications and comorbidities. The implementation of several new diagnostic and screening tools in clinical care, including high-resolution impedance manometry, pH-multichannel intraluminal impedance testing and disease-specific quality of life questionnaires now provide better insight into these problems and may contribute to better long-term outcomes in the future.

Management of recurrent tracheoesophageal fistula after esophageal atresia and follow-up

Recurrent tracheoesophageal fistula (rTEF) is a complex complication after the repair of esophageal atresia (EA) and remains a challenge because of difficulties in preoperative management and the substantial rates of mortality and morbidity after reoperation. By reviewing a single institution's experience in the management of rTEF and assessing the outcome, we aimed to provide an optimal approach for managing rTEF and to evaluate growth and feeding problems after reoperations. The medical records of 35 patients with rTEF treated at a single institution from June 2012 to December 2015 were reviewed, and follow-up data were collected from all survivors. The diagnosis of rTEF was made using a modified esophagram in 32 of 35 patients. Before reoperation, all patients received continuous aspiration to prevent reflux and aspiration pneumonia by placing two nasogastric tubes at the level of the fistula and into the stomach, and they received enteral nutrition through a jejunal feeding tube. Thirty-five patients received a total of 41 reoperations, including 12 operations of fistula resection, 28 reanastomosis, and 1 esophageal replacement. The incidence of postoperative anastomotic leak (AL), anastomotic stricture (AS), and repeat recurrences was 40.0%, 17.1%, and 11.4%, respectively. The mortality rate was 8.6%. All survivors achieved full oral intake. Mid-term follow-up (median of 18 months) revealed that 7 (21.9%) presented prolonged meal time, 6 (18.8%) had feeding refusal, 8 (25.0%) experienced coughing during feeding, and 7 (21.9%) had vomiting during feeding. According to the growth data, 5 survivors (15.6%) presented with growth retardation, including stunting (n = 1), wasting (n = 2), and underweight (n = 2). The modified esophagram is an effective and reliable method for diagnosing rTEF. Optimized preoperative management and surgical techniques lead to a satisfactory outcome. Nevertheless, nutritional evaluation and feeding guidance by a nutritionist after reoperation are recommended.

Categorization and repair of recurrent and acquired tracheoesophageal fistulae occurring after esophageal atresia repair

PURPOSE

Recurrent trachea-esophageal fistula (recTEF) is a frequent (5%-10%) complication of congenital TEF (conTEF) and esophageal atresia (EA) repair. In addition, postoperative acquired TEF (acqTEF) can occur in addition to or even in the absence of prior conTEF in the setting of esophageal anastomotic complications. Reliable repair often proves difficult by endoluminal or standard surgical techniques. We present the results of an approach that reliably identifies the TEF and facilitates airway closure as well as repair of associated tracheal and esophageal problems.

METHODS

Retrospective review of 66 consecutive patients 2009-2016 (55 referrals and 11 local) who underwent repair via reoperative thoracotomy or cervicotomy for recTEF and acqTEF (IRB P00004344). Our surgical approach used complete separation of the airway and esophagus, which reliably revealed the TEF (without need for cannulation) and freed the tissues for primary closure of the trachea and frequently resection of the tracheal diverticulum. For associated esophageal strictures, stricturoplasty or resection was performed. Separation of the suture lines by rotational pexy of the both esophagus and the trachea, and/or tissue interposition were used to further inhibit re-recurrence. For associated severe tracheomalacia, posterior tracheopexy to the anterior spinal ligament was utilized.

RESULTS

The TEFs were recurrent (77%), acquired from esophageal leaks (26%), in addition to persistent or missed H-type (6%). Seven patients in this series had multiple TEFs of more than one category. Of the acqTEF cases, 6 were esophagobronchial, 10 esophagopulmonic, 2 esophagotracheal (initial pure EA cases), and 2 from a gastric conduit to the trachea. Upon referral, 18 patients had failed endoluminal treatments; and open operations for recTEF had failed in 18 patients. Significant pulmonary symptoms were present in all. During repairs, 58% were found to have a large tracheal diverticulum, and 51% had posterior tracheopexy for significant tracheomalacia. For larger esophageal defects, 32% were treated by stricturoplasty and 37% by segmental resection. Rotational pexy of the trachea and/or esophagus was utilized in 62% of cases to achieve optimal suture line separation. Review with a mean follow-up of 35months identified no recurrences, and resolution of pulmonary symptoms in all. Stricture treatment required postoperative dilations in 30, and esophageal replacement in 6 for long strictures. There was one death.

CONCLUSION

This retrospective review of 66 patients with postoperative recurrent and acquired TEF following esophageal atresia repair is the largest such series to date and provides a new categorization for postoperative TEF that helps clarify the diagnostic and therapeutic challenges for management.

Aspiration Risk and Respiratory Complications in Patients with Esophageal Atresia

Chronic, long-term respiratory morbidity (CRM) is common in patients with a history of repaired congenital esophageal atresia, typically associated with tracheoesophageal fistula (EA/TEF). EA/TEF patients are at high risk of having aspiration, and retrospective studies have associated CRM with both recurrent aspiration and atopy. However, studies evaluating the association between CRM in this population and either aspiration or atopy have reported conflicting results. Furthermore, CRM in this population may be due to other related conditions as well, such as tracheomalacia and/or recurrent infections. Aspiration is difficult to confirm, short of lung biopsy. Moreover, even within the largest evidence base assessing the association between CRM and aspiration, which has evaluated the potential relationship between gastroesophageal reflux and asthma, findings are contradictory. Studies attempting to relate CRM to prior aspiration events may inadequately estimate the frequency and severity of previous aspiration episodes. There is convincing evidence documenting that chronic, massive aspiration in patients with repaired EA/TEF is associated with the development of bronchiectasis. While chronic aspiration is likely associated with other CRM in patients with repaired EA/TEF, this does not appear to have been confirmed by the data currently available. Prospective studies that systematically evaluate aspiration risk and allergic disease in patients with repaired EA/TEF and document subsequent CRM will be needed to clarify the causes of CRM in this population. Given the prevalence of CRM, patients with repaired EA/TEF should ideally receive regular follow-up by multidisciplinary teams with expertise in this condition, throughout both childhood and adulthood.

Peri-operative management of neonates with oesophageal atresia and tracheo-oesophageal fistula

Oesphageal atresia is a relatively common congenital anomaly that requires urgent diagnosis, transfer to a neonatal surgical centre and management by a multidisciplinary team. Peri-operative management requires vigilant monitoring for the many possible associated morbidities. There are unique anaesthetic, airway and ventilatory considerations for this group of patients. Beyond the perinatal period, systematic neurodevelopmental follow-up is recommended to better understand the longer term outcomes for these children.

Esophageal atresia: a critical review of management at a single center in Algeria

The purpose was to study the outcomes and factors affecting the survival of esophageal atresia in our center. A retrospective analysis of 86 cases of esophageal atresia (EA) over a 10-year period was performed with 46 boys and 42 girls. Demographic data, birth weight, gestational age, consanguinity, incidence of associated anomalies, place of delivery, history of feeding, and outcomes were studied. EA with distal tracheoesophageal fistula (TEF) was the commonest type with 58/86 (67%). The percentage of patients with at least one associated anomaly was 52/86 (60%), with 7/86 (8%) who are from consanguineous parents; most commonly associated anomalies were cardiac 13/86 (15%). The average gestational age and birth weight were 36 ± 2 weeks and 2300 ± 570 g, respectively. Survival rates for the patients according to the Waterston classification was 80% in group A, 58% in group B, and 25% in group C (three patients died before surgery). Prematurity, the gap between the two ends of the esophagus, and preoperative respiratory status were the most significant factors affecting the survival. Late complication of EA/TEF include respiratory symptoms, especially in the first year, associating tracheomalacia and bronchopulmonary infections in about 24/45 (53%), recurrence of TEF 3/45 (7%), esophageal stricture 26/45 (58%), and gastroesophageal reflux 22/45 (49%). The high incidence of delayed diagnosis, low birth weight, and lack of advanced neonatological management are important contributory factors to the poor outcome. The frequency of late complications highlights the need for multidisciplinary clinics to follow these children's.

Incidental tracheal diverticulum discovered 30 years after tracheo-esophageal fistula repair

Tracheo-esophageal fistula is a well-described congenital abnormality treated surgically upon diagnosis. Although respiratory-related and reflux-related complications are frequent, recurrent fistula and diverticulum can occur. This case report describes the rare occurrence of a gross type B fistula repaired at birth, which was then asymptomatic for nearly 30 years until presentation with chest pain. Upon workup, the patient was found to have an isolated tracheal diverticulum without recurrent fistula. We highlight the need for a focused workup despite the length of time since fistula repair and the varied treatment modalities described in the literature.

Slide tracheoplasty for the treatment of tracheoesophogeal fistulas

PURPOSE

The purpose of this study is to determine the surgical outcome of slide tracheoplasty for the treatment of tracheoesophageal (TE) fistula in pediatric patients.

METHODS

After internal review board approval, the charts of pediatric patients (0-18years old) who had undergone slide tracheoplasty for tracheoesophageal fistula were retrospectively reviewed. Patient information and surgical outcomes were reviewed.

RESULTS

Nine patients underwent slide tracheoplasty for correction of TE fistula. In five patients the original TE fistula was congenital. Other causes included battery ingestion, tracheostomy tube complications, foreign body erosion, and an iatrogenic injury. The average age at repair was 48±64 months (range: 1-190). Seven patients had undergone previous TEF repair either open or endoscopically. There were no recurrences after repair. Two patients had sternal periosteum interposed between the esophagus and trachea. There were no TEF recurrences. A single patient had dehiscence of the tracheal anastomosis and underwent a second procedure.

CONCLUSION

Slide tracheoplasty is an effective method to treat complex TE fistulas. The procedure was not associated with any recurrences. This is the first description of a novel, effective, and safe method to treat TE fistulas.

A standardised investigative strategy prior to revisional oesophageal surgery in children: High incidence of unexpected findings

BACKGROUND/PURPOSE

Revisional oesophageal reconstructive surgery carries uncommon and unusual risks related to previous surgery. To provide maximum anatomical detail and facilitate successful outcome, we report a standardised pre-operative investigative strategy for all such patients.

METHODS

Prospective 8-month cohort study following the introduction of this strategy. All patients underwent high resolution thoracic contrast CT scan and micro-laryngo-bronchoscopy by a paediatric ENT surgeon in addition to upper gastrointestinal contrast study, oesophagoscopy, and echocardiogram.

RESULTS

Seven children (median age 5.6 months [range 2.2-60]) completed the pathway. Four were referred with recurrence of a previously divided tracheo-oesophageal fistula (3 congenital, 1 acquired) and 3 (all with oesophagostomy) for oesophageal replacement for congenital isolated oesophageal atresia (OA, n=1) and failed repair of OA with distal TOF with wide gap (n=2). Overall, unanticipated findings were demonstrated in 6/7 children and comprised severe tracheomalacia and right main bronchus stenosis requiring aortopexy (n=1), vocal cord palsy (n=2), extensive mediastinal rotation (n=1), proximal tracheal diverticulum (n=1), severe subglottic stenosis requiring airway reconstruction (n=1), proximal tracheal diverticulum (n=1), right sided aortic arch (n=1) and left sided aortic arch (previously reported to be right sided, n=1).

CONCLUSIONS

This standardised approach for this complex group of patients reveals a high incidence of unexpected anatomical and functional anomalies with significant surgical and possible medico-legal implications. We recommend these investigations during the pre-operative work-up prior to all revisional oesophageal surgery.

Redo esophageal surgery: the diagnosis and management of recurrent tracheoesophageal fistula

This article presents a 30-year review of 38 recurrent tracheoesophageal fistulas. The initial 26 cases were presented in 2009 at the annual meeting of the British Association of Pediatric Surgeons and the European Association of Pediatric Surgeons Joint Conference and published in the Journal of Pediatric Surgery (Bruchet al. J Pediatr Surg 45:337-340, 2010). In the initial cohort of 26 patients, 18 had a leak after their primary operation and 22 had respiratory symptoms leading to the discovery of the recurrent fistula. The diagnosis was made by a contrast study in 24. The repairs entailed replacing a catheter through the fistula, separating the trachea and esophagus completely using sharp dissection and placing vascularized tissue, either pleura or pericardium between the suture lines. Postoperative complications included seven anastomotic leaks, four strictures and three recurrent fistulas. Long-term follow-up (median of 84 months) showed that 21 took all of their nutrition by mouth, three were tube fed and two required a combination of both. Of the 23 patients with growth chart data, 16 fell into the first quartile of the growth chart, whereas none fell between the 75th and 100th percentile. In conclusion, this initial series of 26 patients along with the updated additional series of 12 patients is the largest series thus far reported in the literature. All 38 patients represent the characteristics of recurrent tracheoesophageal fistulas, including techniques to make the diagnosis and to provide a secure closure of the fistula, and the long-term outcomes of these patients.

Postoperative appearances of esophageal atresia repair: retrospective study of 210 patients with review of literature - what the radiologist should know

BACKGROUND

Primary surgical repair forms the definitive treatment of esophageal atresia. Long-term survival rates and patient morbidity after repair still remains a problem especially in developing countries. Postoperative morbidity depends on the incidence of anastomotic leak, gastroesophageal reflux, strictures, and recurrent fistula formation.

PURPOSE

To describe the frequency of different findings at fluoroscopic evaluation of postoperative esophagus in children following repair for esophageal atresia with or without tracheo-esophageal fistula.

MATERIAL AND METHODS

Hospital records and upper gastrointestinal contrast studies of 210 patients following repair for esophageal atresia with or without a tracheo-esophageal fistula were reviewed by two pediatric radiologists. All children underwent surgery in the first few days of life (days 1-6). Fluoroscopic contrast study was performed at various intervals after surgery in children with suspected complications or feeding difficulties.

RESULTS

Images from upper gastrointestinal contrast studies of 210 patients (126 boys, 84 girls) were evaluated and recorded. Findings were recorded as normal postoperative appearances (37.1%) and complications/sequelae, which included strictures (33.8%), minor and major leaks (11.9%), reflux (13.8%), motility problems (7.1%), persistent fistula (3.8%), diverticulae formation (4.7%), and hiatus hernia (2.1%).

CONCLUSION

Strictures, leaks, and reflux are the most common complications of esophageal atresia repair. Knowledge of various postoperative appearances would be useful for planning an appropriate management strategy in these children.

Long term respiratory outcomes of congenital diaphragmatic hernia, esophageal atresia, and cardiovascular anomalies

Intrathoracic congenital malformations may be associated with long-term pulmonary morbidity. This certainly is the case for congenital diaphragmatic hernia, esophageal atresia and cardiac and aortic arch abnormalities. These conditions have variable degrees of impaired development of both the airways and lung vasculature, with a postnatal impact on lung function and bronchial reactivity. Pulmonary complications are themselves frequently associated to non-pulmonary morbidities, including gastrointestinal and orthopaedic complications. These are best recognized in a structured multidisciplinary follow-up clinic so that they can be actively managed.

Oesophageal atresia and tracheo-oesophageal fistula: current management strategies and complications

The successful operative management of oesophageal atresia and tracheo-oesophageal atresia has been available for approximately 70 years. During this time neonatal intensive care has evolved, surgical techniques have improved and consequently near 100% survival for this condition may now be achieved. In keeping with promising results, the co-morbidities of the condition have gained increasing recognition. In this article, the clinical course from antenatal assessments, neonatal surgery and co-morbidities from infancy to adulthood are reviewed to provide a broad overview of the condition.

KTP laser: an important tool in refractory recurrent tracheo-esophageal fistula in children

Secondary tracheo-oesophageal fistula in delayed primary repair of oesophageal atresia is rare. This paper reports the successful use of the KTP laser in the treatment of this condition in a refractory case. It also recommends the use of direct laryngotracheobronchoscopy (DLTB) in the diagnosis. We recommend the use of this laser in cases of recurrent tracheo-esophageal fistula especially when other means have failed.

The diagnosis and management of recurrent tracheoesophageal fistulas

PURPOSE

This review provides a blueprint to deal with the diagnosis and management of recurrent tracheoesophageal fistulas.

METHODS

A retrospective review over 27 years found 26 recurrent tracheoesophageal fistulas. Descriptive statistical analyses were performed.

RESULTS

In this cohort of 26 patients, 18 had a leak after their primary operation; and 22 had respiratory symptoms leading to the discovery of the recurrent fistula. The diagnosis was made by contrast study in 24. The repairs entailed placing a catheter through the fistula; separating the trachea and esophagus using sharp dissection; and placing tissue, preferably pericardium, between the suture lines. Postoperative complications included 7 anastamotic leaks, 4 strictures, and 3 recurrent fistulas. Long-term follow-up (median of 84 months) showed that 21 took all of their nutrition by mouth, 3 were tube fed, and 2 required a combination. Of the 23 patients with growth chart data, 16 fell in the first quartile of the growth chart, whereas none fell between the 75th and 100th percentile.

CONCLUSION

This series, the largest to date, describes characteristics of recurrent tracheoesophageal fistulas, including techniques to make the diagnosis and provide a secure closure of the fistula, and the long-term outcomes of these patients.

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.

Esophageal atresia repair with thoracotomy: the Cincinnati contemporary experience

Esophageal atresia/tracheoesophageal fistula (EA/TEF) repair using an open muscle-sparing thoracotomy has been the standard approach used in our institution. Whereas perioperative mortality is now very uncommon, short- and long-term morbidity is very common in these patients. However, the complexity of the esophageal anatomy and significant comorbidities appear to be important contributors to significant complications in these patients. At least 30% of the EA/TEF patients required esophageal dilatations for anastomotic stricture; this increased to 50% for patients with pure EA. Gastroesophageal reflux requiring an antireflux procedure was performed 23% of the time for EA/TEF and 30% for EA patients. In addition, there were a few complications, such as winging of the scapula and scoliosis, that were attributed in part to the utilization of a nonmuscle-sparing thoracotomy. The standard muscle-sparing thoracotomy remains a very versatile and useful approach to repairing esophageal atresia, and it is the standard for repairing more complex anatomical variants. The self-reported long-term quality of life in these patients is very good, except for a few individuals with protracted feeding disorders and severe dysphagia.

Endoscopic management of recurrent tracheoesophageal fistula

RATIONALE

Recurrent tracheoesophageal fistulas (RTEFs) remain a therapeutic challenge because open surgical approaches have been associated with substantial rates of morbidity, mortality, and repeat recurrences. Recently, endoscopic techniques for the repair of RTEF have provided an alternative approach with the potential for improved surgical outcomes. However, previous reports have been limited by small patient numbers and variations in technique. By examining a single institution's experience and performing a systematic review of previously published results, we aimed to identify an optimal approach to managing RTEF endoscopically.

METHODS

Retrospective chart review of patients undergoing endoscopic management of RTEF at a single tertiary care institution was performed. Medline search and summated analysis of previously published cases of endoscopically treated RTEF from 1975 to 2007 was conducted.

RESULTS

Four patients with RTEF were identified and selected for endoscopic repair at our institution from 2003 to 2007 (mean age, 11.5 months). Under endoscopic guidance, fistula tracts were de-epithelialized with a Bugbee fulgurating diathermy electrode (5-15 W) and then sealed with fibrin glue (Tisseel with added aprotinin). Closure of RTEF was successful in 3 patients after a single attempt. One revision was required after inadvertent recannulation of the tract with an emergent tracheostomy tube change. No patient has evidence of recurrence (mean follow-up, 16 months). In 15 articles of endoscopically repaired RTEF, 37 cases have been reported from 1975 until present. In general, 3 approaches to endoscopic repair have been explored. Analysis of all reported cases in the literature and results from our patient series suggests that endoscopic techniques designed to both de-epithelialize the fistula tract and seal with fibrin glue have the best chance for cure after a single attempt. Patients with long, thin, and small diameter fistula who have enough distal trachea to accommodate a postoperative cuffed ventilating tube beyond the fistula are ideal candidates for endoscopic repair.

CONCLUSION

In select patients, endoscopic management of RTEF using Bugbee cautery and tissue adhesives can reduce morbidity and recurrence associated with open approaches and alternative endoscopic techniques.

Oesophageal atresia

Oesophageal atresia (OA) encompasses a group of congenital anomalies comprising of an interruption of the continuity of the oesophagus with or without a persistent communication with the trachea. In 86% of cases there is a distal tracheooesophageal fistula, in 7% there is no fistulous connection, while in 4% there is a tracheooesophageal fistula without atresia. OA occurs in 1 in 2500 live births. Infants with OA are unable to swallow saliva and are noted to have excessive salivation requiring repeated suctioning. Associated anomalies occur in 50% of cases, the majority involving one or more of the VACTERL association (vertebral, anorectal, cardiac, tracheooesophageal, renal and limb defects). The aetiology is largely unknown and is likely to be multifactorial, however, various clues have been uncovered in animal experiments particularly defects in the expression of the gene Sonic hedgehog (Shh). The vast majority of cases are sporadic and the recurrence risk for siblings is 1%. The diagnosis may be suspected prenatally by a small or absent stomach bubble on antenatal ultrasound scan at around 18 weeks gestation. The likelihood of an atresia is increased by the presence of polyhydramnios. A nasogastric tube should be passed at birth in all infants born to a mother with polyhydramnios as well as to infants who are excessively mucusy soon after delivery to establish or refute the diagnosis. In OA the tube will not progress beyond 10 cm from the mouth (confirmation is by plain X-ray of the chest and abdomen). Definitive management comprises disconnection of the tracheooesophageal fistula, closure of the tracheal defect and primary anastomosis of the oesophagus. Where there is a "long gap" between the ends of the oesophagus, delayed primary repair should be attempted. Only very rarely will an oesophageal replacement be required. Survival is directly related to birth weight and to the presence of a major cardiac defect. Infants weighing over 1500 g and having no major cardiac problem should have a near 100% survival, while the presence of one of the risk factors reduces survival to 80% and further to 30–50% in the presence of both risk factors.

Esophageal atresia. Lessons I have learned in a 40-year experience

A brief resume of the highlights in the history of oesophageal atresia is presented. This is followed by research into the etiology, ontogeny and embryology, and microbiological studies. A revised classification of risk factors with consequent survival statistics is presented. Lessons learned in the management of the condition over a 40-year period are reported with particular emphasis on the management of the preterm infant with associated severe respiratory distress, right-side aortic arch, upper pouch fistula, 'long-gap' atresia, and the use of gastrostomy and intercostals drains. The incidence and treatment of early and late complications is discussed.

Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula

Congenital esophageal atresia (EA) and/or tracheoesophageal fistula (TEF) are common congenital anomalies. Respiratory and GI complications occur frequently, and may persist lifelong. Late complications of EA/TEF include tracheomalacia, a recurrence of the TEF, esophageal stricture, and gastroesophageal reflux. These complications may lead to a brassy or honking-type cough, dysphagia, recurrent pneumonia, obstructive and restrictive ventilatory defects, and airway hyperreactivity. Aspiration should be excluded in children and adults with a history of EA/TEF who present with respiratory symptoms and/or recurrent lower respiratory infections, to prevent chronic pulmonary disease.

Median sternotomy and use of a pedicled sternocleidomastoid muscle flap in the management of recurrent tracheoesophageal fistula

Recurrent tracheoesophageal fistula may complicate primary repair of congenital tracheoesophageal fistula. Standard treatment involves repair via a right lateral thoracotomy and use of adjacent soft tissues to separate the suture lines of the fistulous openings. The authors describe an alternative approach via a median sternotomy, which improves access, reduces the operating time required to identify the recurrent fistula, and enables the use of a pedicled sternocleidomastoid muscle flap to decrease the risk of refistulization.

Congenital tracheoesophageal fistula: preventing recurrence

Recurrent tracheoesophageal fistula is a major complication of surgical therapy among children with congenital esophageal atresia and tracheoesophageal fistula. In a consecutive series of 153 patients operated on during a 20-year period in the same institution, only one patient had this complication. The authors believe that adherence to sound surgical principles can lower the risk of fistula recurrence considerably.

Newborn surgical emergencies. Gastrointestinal anomalies, abdominal wall defects

Structural anomalies of the gastrointestinal tract and anterior abdominal wall diagnosed in the perinatal period often require prompt surgical intervention. This article highlights the pathophysiology, evaluation, and management of the more common lesions encountered in the neonate.

Management of esophageal atresia

A total of 303 infants with esophageal atresia and/or tracheoesophageal fistula were treated over 10 years (1980-1989). The overall survival rate was 86.5%. Associated anomalies were identified in 51.8% of patients, the most common being cardiac malformations which affected 24.4% of infants and was responsible for the majority of deaths. The dramatic increase in survival of infants with esophageal atresia in the past half century is due to improvements in pre- and postoperative management, meticulous operative technique to reduce anastomotic complications, and aggressive treatment of associated congenital anomalies.

Anastomotic leakage following surgery for esophageal atresia

Of 199 neonates undergoing primary or delayed primary repair of esophageal atresia, 34 (17%) developed anastomotic leakage, 7 of which (3.5%) were major anastomotic disruptions. Infants with major leaks developed signs within 5 days and all required early reoperation, necessitating abandonment of the esophagus in 6. The remaining 27 were minor leaks demonstrated by water-soluble contrast studies and were successfully treated nonoperatively. Gastroesophageal reflux was unassociated with this complication but the use of braided silk sutures was associated with a significantly increased risk of anastomotic leakage when compared with polyglycolic acid (relative risk, 3.2) or polypropylene (relative risk, 2.6) sutures. Following anastomotic leakage there was a significantly increased risk (relative risk, 2.04) of subsequent esophageal stricture formation.

Paediatric emergencies

During the last decade neonatal surgical results have improved considerably. Except for infants born with serious congenital heart disease, diaphragmatic hernia or exomphalos, postoperative mortality rates for infants with single anomalies have fallen to the region of 10%. This dramatic success story has been marred by a corresponding increase in the number of individuals with several anomalies entering late childhood with severe chronic handicaps. During the remainder of this century much effort will be expended in devising programmes of investigation which will attempt to predict which individuals will have a poor long-term prognosis. Such programmes will necessitate very close liaison between obstetricians, radiologists, neonatologists, local paediatricians, paediatric surgeons, general practitioners and parents. Very urgent surgery is necessary for the best results in infants with gastroschisis, intestinal volvulus and irreducible inguinal hernia, but for most other conditions there have been recent trends away from very urgent surgery to operation during daylight hours within the ensuing 24 h. Surgery within a few hours of presentation is necessary for intussusception and for early acute appendicitis, but perforated appendicitis should be treated by aggressive fluid replacement and intravenous antibiotics and surgery should be contemplated only in the rare cases of continued deterioration.