Tracheoesophageal fistula formation in intubated patients. Risk factors and treatment with high-frequency jet ventilation

Acquired tracheoesophageal fistula in a pregnant patient with COVID-19 pneumonia on prolonged invasive ventilation

A previously healthy pregnant woman was diagnosed with COVID-19 pneumonia and was subsequently intubated. Throughout the course of her illness, the patient was treated for recurrent bouts of pneumonia. A high-resolution chest and neck CT scan confirmed the presence of a tracheoesophageal fistula (TEF), which may have been caused by the presence of the overinflated endotracheal cuff, prolonged steroid use, hypoxic injury and possible direct injury of the tracheal mucosa from COVID-19 itself. A temporising procedure, involving tracheostomy with an extended-length tracheal tube, was performed. Unfortunately, the patient succumbed to infection prior to definitive repair. This case highlights the importance of keeping a high index of suspicion for tracheal injury in patients who experience prolonged periods of intubation. It also underlies the high morbidity and mortality rate associated with TEF, although being a rare disease.

Stapled Repair of Benign Acquired Tracheoesophageal Fistula: Description of Novel Technique and Assessment of Outcomes

Compared to less invasive measures, surgical repair is the most effective modality for managing benign acquired tracheoesophageal fistula (TEF). Traditionally, this involves dismantling of the fistula and suture repair of tracheal and esophageal defects using a lateral or direct approach. However, the best approach remains a subject of debate. We describe a novel and simple technique for dismantling a benign acquired TEF with the use of an endo-stapler and interposition with sternocleidomastoid (SCM) muscle flap. Eleven TEF patients underwent repair using this stapled repair technique. Retrospectively, the perioperative and long-term outcomes were assessed in these patients. There were no cases of procedure-related mortality or airway-related complications. Two patients developed transient vocal cord palsy and one developed esophageal leak. At a mean follow-up of 21.4 months, no fistula recurrence, dysphagia, or tracheal stenosis was observed. Hence stapled dismantling and SCM muscle interposition is a simple and safe technique for repair of benign acquired TEF.

Direct and indirect CT imaging features of esophago-airway fistula in adults

Background

Esophago-airway fistula (EAF) is an abnormal connection between the esophagus and the trachea or a major bronchus. While contrast esophagography remains the primary radiographic tool for the diagnosis of EAF, computed tomography (CT) is often employed in its evaluation. A systematic analysis of CT findings of EAF in adults has not been previously published. The goal of our study is to determine the direct and indirect CT findings of EAF in adults.

Methods

We identified patients with EAF detected on CT at our institution between January 1, 2001 and December 31, 2019, with endoscopic or surgical confirmation. We collected patient clinicopathologic characteristics and assessed CTs for direct and indirect imaging features of EAF in these patients.

Results

Twenty-six patients (median age: 56 years; range, 25–79 years; F=13, 50% and M=13, 50%) with confirmed EAF were identified. Half of the patients had an underlying malignancy. On CT, a direct connection between the esophagus and the airway was identified in most cases (22/26; 85%). Common indirect CT findings of EAF included esophageal wall thickening (21/26, 81%), mediastinal fatty stranding (21/26, 81%), airway wall thickening (20/26, 77%), fluid or debris within the airways (17/26, 65%), and focal or diffuse esophageal dilation with air (17/26, 65%). Mediastinal fluid collections were infrequently seen (4/26, 15%), but findings of aspiration or other pneumonia were common (19/26, 73%).

Conclusions

CT plays an essential role in both the primary and secondary evaluation of adult EAF resulting from both malignant and benign etiologies. CT may be the first diagnostic exam to suggest and detect the presence of EAF and may precede clinical suspicion, and it can detect a subset of fistulas not demonstrated on esophagography. There are several direct and indirect imaging findings on CT that can help in the detection of EAF.

Surgery and perioperative management for post-intubation tracheoesophageal fistula: case series analysis

BACKGROUND

Post-intubation tracheoesophageal fistula (PITEF) is an often mistreated, severe condition. This case series reviewed for both the choice and timing of surgical technique and outcome PITEF patients.

METHODS

This case series reviewed ten consecutive patients who had undergone esophageal defect repair and airway resection/reconstruction between 2000 and 2014. All cases were examined for patients: general condition, medical history, preparation to surgery, diagnostic work-up, timing of surgery and procedure, fistula size and site, ventilation type, nutrition, post-operative course and complications.

RESULTS

All patients were treated according to Grillo's technique. Overall, 6/10 patients had undergone a preliminary period of medical preparation. Additionally, 3 patients had already had a tracheostomy, one had had a gastrostomy and 4 had both. One patient had a Dumon stent with enlargement of the fistula. Concomitant tracheal stenosis had been found in 7 patients. The mean length of the fistulas was 20.5 mm (median 17.5 mm; range, 8-45 mm), at a median distance from the glottis of 43 mm (range, 20-68 mm). Tracheal resection was performed in all ten cases. The fistula was included in the resection in 6 patients, while it was excluded in the remaining 4 due to their distance. Post-repair tracheotomy was performed in 3 patients. The procedure was performed in 2 ventilated patients. Morbidity related to fistula and anastomosis was recorded in 3 patients (30%), with one postoperative death (10%); T-Tube placement was necessary in 3 patients, with 2/3 decannulations after long-stenting. Definitive PITEF closure was obtained for all patients. At 5-year follow-up, the 9 surviving patients had no fistula-related morbidity.

CONCLUSIONS

Primary esophageal closure with tracheal resection/reconstruction seemed to be effective treatment both short and long-term. Systemic conditions, mechanical ventilation, detailed preoperative assessment and appropriate preparation were associated with outcome. Indeed, the 3 patients who had received T-Tube recovered from anastomotic complications.

Management of the chronically ventilated patient with a tracheostomy

Tracheostomy is the most common surgical procedure performed on critically ill patients. For those who survive their critical illnesses but remain ventilator-dependent, tracheostomy provides patients with a secure airway that frees the mouth for oral nutrition, enhances verbalized speech, and promotes generalized comfort. Avoiding complications from tracheostomy requires a skilled multi-disciplinary approach to ensure that the benefits outweigh the risks of the procedure.

Tracheomegaly and tracheosephagial fistula following mechanical ventilation: A case report and review of the literature

Postintubation Tracheoesophageal fistula (TEF) is a rare complication. Acquired TEF most commonly occurred following prolonged mechanical ventilation with an endotracheal or tracheostomy tube, cuff-related tracheal injury, post-intubation injury. We present a case of both tracheomegaly and tracheosephagial fistula following mechanical ventilation for 15 days, in the light of the literature.

Bronchial-oesophageal fistula: a rare initial presentation of squamous cell carcinoma of the lung

A 61-year-old Caucasian man with hypertension and hepatitis C presented to the emergency department with 7 days of productive cough and low-grade fevers despite outpatient therapy with oral azithromycin. On initial evaluation, he was lethargic with peripheral cyanosis and oxygen saturation in the low 70 s on room air, necessitating endotracheal intubation. Chest imaging revealed diffuse bilateral infiltrates compatible with the diagnosis of acute respiratory distress syndrome. Patient subsequently developed profound hypoxaemia and on day 2 of admission, veno-veno extracorporeal membrane oxygenation (ECMO) was initiated. Bronchoscopy revealed a necrotic ulcer on the posterior wall of the left mainstem bronchus, compatible with a bronchial-oesophageal fistula, which was later confirmed by endoscopy, and stented. Histology revealed poorly differentiated squamous cell carcinoma of the lung. Despite stenting of the fistula and ECMO support, the patient expired 5 days after admission.

Endoscopic Occlusion of Tracheoesophageal Fistula in Ventilated Patients Using an Amplatzer Septal Occluder

Acquired tracheoesophageal fistula (TEF) is a challenging, life threatening condition. It most commonly appears in critically ill patients requiring prolonged mechanical ventilation, who cannot withstand open neck or chest surgery. An endoscopic technique could be better tolerated by these patients. We present our experience using a cardiac Amplatzer ASD septal occluder for an endoscopic TEF repair in ventilation-dependent patients. Two high risk patients underwent the procedure under general anesthesia and close respiratory monitoring. In one patient the device was inserted through the trachea and in the other through the esophagus. In both cases fistula closure was achieved for different periods of time allowing the patients a temporary relief of symptoms. The procedure was well tolerated by the patients, and no significant adverse effect documented. The technique was successful as a temporary solution for unstable patients with TEFs and should be considered as a treatment modality for similar patients.

Complete healing of tracheoesophageal fistula in a ventilator-dependent patient by conservative treatment

Acquired nonmalignant tracheoesophageal fistula (TEF) is a rare clinical condition with multiple etiologies, although post-intubation injury is the most common cause. TEFs can be fatal if left untreated due to devastating pulmonary complications caused by tracheobronchial contamination and poor nutrition. Herein, we present a case of complete healing of a post-intubation TEF under conservative treatment in a ventilator-dependent patient, and review previous studies regarding the treatment of acquired nonmalignant TEFs.

Early and late outcome after surgical treatment of acquired non-malignant tracheo-oesophageal fistulae

OBJECTIVES

Tracheo-oesophageal fistula (TOF) is a rare, life-threatening condition. We report our results of surgical treatment and evaluation of the outcome of acquired non-malignant TOF.

METHODS

Twenty-five patients (aged 49 ± 21 years) with TOF were operated on between 2001 and 2011. Tracheo-oesophageal fistula was due to prolonged intubation/tracheostomy (84%), was secondary to other surgery (8%) or trauma (4%) or was idiopathic (4%). The tracheal defect was 2.4 ± 1.3 cm long and was associated with tracheal stenosis in seven (28%) patients. Surgical treatment consisted of direct suturing of the oesophageal defect in two layers (or end-to-end oesophageal resection and anastomosis in one case) associated with tracheal suturing (n = 15; 60%), tracheal resection and anastomosis (n = 8; 32%) or covering of a large tracheal defect by an intercostal muscle flap or by a resorbable patch with muscle apposition (n = 2; 8%). The surgical approach was cervicotomy (n = 14; 56%), cervicotomy plus median sternotomy or split (n = 6; 24%), thoracotomy (n = 4; 16%) or cervicotomy plus sternal spit plus thoracotomy (n = 1; 4%). In 18 (72%) cases a muscular flap was used and in six (24%) a protective tracheostomy was performed.

RESULTS

No perioperative deaths occurred. Morbidity occurred in eight (32%) patients; none of them required a second surgical look. At median follow-up of 41 months, the outcome was excellent or good for 22 patients (88%), two (8%) are still dependent on jejunostomy and tracheostomy for neurological diseases and one (4%) is under mechanical ventilation for end-stage respiratory failure.

CONCLUSIONS

Surgical treatment of TOF is associated with good results in terms of control of acute symptoms and long-term outcome, particularly concerning oral intake and spontaneous breathing.

[Complication of tracheal intubation: severe cervical cellulitis]

A 40-year-old man, victim of a traffic accident has been hospitalized for a severe head trauma. His trachea has been intubated under general anaesthesia with an 8.0 mm ID tube (Vygon). The cerebral scan revealed a surgical subdural haematoma. In the postoperative period, the patient was admitted in surgical intensive care, under sedation and mechanically ventilation. At day 12 the patient developed a cervical cellulitis complicated of a septic shock. The cervical scan showed an important dilatation of the trachea in the site of the tube cuff. The surgical exploration discovered a complete destruction of the anterior face of de trachea on several centimetres of height. The patient died 24 hours later by multiple organ failure.

Temporary stenting of acquired benign tracheoesophageal fistulas in critically ill ventilated patients

BACKGROUND

To evaluate the use of esophageal stents for temporary sealing of acquired benign tracheoesophageal fistulas developed in critically ill, ventilated patients.

METHODS

This is a retrospective analysis (1992-2003) of the data of 12 mechanically ventilated patients - six of them after major or multiple trauma - being intubated for a median of 30 days before they develop an acquired benign tracheoesophageal fistula. Five of them were in sepsis. Two types of stents were used: the Wilson-Cook esophageal balloon plastic stent in the first four cases and the Ultraflex covered self-expandable stent in the remaining eight. The total procedure was performed at bedside in the intensive care unit, with no special need for supplementary anesthesia or fluoroscopic control.

RESULTS

Stent implantation was technically successful in all patients and fistula occlusion was achieved in every case. There was no stent migration and fistulas remained sealed until death or upon decision for removal. Nine patients died between 5 days and 2 months after stent placement, as a result of their diseases. Three patients were referred for fistula surgical repair 33, 36, and 43 days after stent placement. Before surgery the stents were easily removed under direct vision.

CONCLUSION

Temporary closure of an acquired tracheoesophageal fistula developed in critically ill ventilated patients is an easy, bedside-applicable, safe, and effective palliative procedure, with no complications or mortality.

Fístula traqueoesofágica en paciente intubado: tratamiento mediante exclusión y patch esofágico

Currently, acquired benign tracheoesophageal fistulas are mainly iatrogenic lesions produced by prolonged tracheal intubation. Their occurrence in intubated patients is infrequent but devastating and their therapeutic resolution is highly complex. We present the case of a patient with an extensive tracheoesophageal fistula following tracheal intubation that was surgically treated through esophageal exclusion (cervical esophagostomy and suture-stapling of the distal esophagus) and closure of the tracheal defect using the posterior esophageal wall.

Tracheal stenosis complicated with tracheoesophageal fistula

OBJECTIVE

The aim of the present study was to evaluate the results of surgical treatment in patients with simultaneous occurrence of postintubation tracheal stenosis (TS) and tracheoesophageal fistula (TEF).

METHODS

In the group of 51 patients with postcannulation tracheal stenosis who underwent segmental resection, TEF was identified simultaneously in five (10%) of them. The mean age of the TS-TEF patients was 43 years (range 35-60 years). The patients underwent a single-stage operation during which TEF was sealed and resection of the stenotic tracheal segment was performed.

RESULTS

The cause of TEF and of TS was artificial pulmonary ventilation by tracheostomy tube (n=4) or by endotracheal tube (n=1) with a simultaneous insertion of nasogastric tube. In one of the patients with tracheostomy the fistula resulted from an injury to the pars membranacea tracheae and the esophageal wall during tracheostomy. All the patients were respiring spontaneously before the surgical treatment. The mean length of the fistula was 24.0 mm (range 15-30 mm), the fistulae were located at the junction of the upper and middle third of the trachea. The mean length of the resected tracheal segment was 29.6 mm (range 26-32 mm). Postoperative complications were not observed in the group of the TS-TEF patients, none of them died.

CONCLUSIONS

The method of choice of the surgical treatment of TEF associated with TS is a single-stage procedure in the patient who respires spontaneously.

Management of an acquired tracheoesophageal fistula with a fascial free flap

BACKGROUND

Failure in the primary repair of a benign acquired tracheoesophageal fistula limits the operative options available at revision. Use of a fascial free flap to treat this condition has not been previously reported.

METHODS

We review the case of a patient who had a tracheoesophageal fistula develop after percutaneous tracheostomy, who had failed previous primary repair with strap muscle interposition.

RESULTS

A radial forearm fascial free flap was used at revision and resulted in resolution of the fistula.

CONCLUSION

Use of a fascial free flap to address a persistent acquired tracheoesophageal fistula, when an accompanying stenotic segment is not present, is a viable treatment option.

Tracheostomy management in the chronically ventilated patient

Tracheotomy is a fundamentally important technique for managing patients who require long-term mechanical ventilation. Appropriate application of tracheotomy requires a skilled approach for timing the procedure, selecting the appropriate tracheostomy tube appliance, caring for the artificial airway once it is in place, and assisting patients with their specialized needs, such as articulated speech, airway humidification, and oral nutrition. Preparing patients for airway decannulation after they have weaned from mechanical ventilation requires a similar level of skill and attention to detail.

Acquired tracheoesophageal fistula in critically ill patients

Acquired benign tracheoesophageal fistula (TEF) is an infrequent complication of prolonged intubation and tracheostomy. Not infrequently, it is associated with severe circumferential malacia of the trachea and a need for concomitant correction of both. Controversy exists as to whether this should be performed in a single-stage or a 2-stage procedure. Four patients with acquired TEF underwent operation in a tertiary referral medical center between 1995 and 1997. The operations were performed through either an anterior (3) or a lateral (1) neck approach. Three patients underwent closure of the fistula with tracheal resection and anastomosis in a single stage and are doing well. One patient with complete subglottic stenosis underwent closure of the TEF and was planned for tracheal reconstruction in a second stage. This patient died in the early postoperative period. The complications included aspiration of blood leading to pneumonia (2), spontaneously resolving pneumomediastinum (1), subcutaneous emphysema (2), and cardiac arrhythmia ( 1). Residual fistula, noted in 1 patient, was treated conservatively and resolved spontaneously within several weeks. We conclude that acquired TEF is amenable to repair through a cervical approach. A single-stage correction of the TEF with reconstruction of the trachea is suitable and successful in most patients. Several stages seem justified when concurrent laryngotracheal reconstruction is needed.

Acquired tracheo-esophageal fistula in the pediatric population

Acquired tracheo-esophageal fistula (TEF) in the paediatric population is a rare entity, an acquired fistula can be due to tracheotomy tubes and tracheotomy cuffs. Patients with burns are at greater risk from these tracheotomy complications. Acquired TEF can also occur due to a foreign body impaction. Prevention and early diagnosis are important. In patients with possible airway burns, 'safe' intracuff pressures maybe too high. To avoid further damage of the mucosa, the patient should have a small air leak maintained if a cuff is used. Most acquired TEF do not close spontaneously and surgical closure is required. Our paper presents two cases of acquired TEF in the pediatric population and reviews the literature on this subject.

Diagnosis of tracheoesophageal fistula by analysis of gastric air

Two patients receiving positive pressure ventilation experienced marked gaseous abdominal distension. Analysis of gases from the stomach, ventilator, and room air suggested that the gastric gases came from the ventilator in one patient. The diagnosis of tracheoesophageal fistula was confirmed by esophagoscopy. Analysis of gases in the other patient did not support the suspicion of tracheoesophageal fistula, and no fistula was found at autopsy. The technique of gastric air analysis is presented as a simple supporting tool for the clinical diagnosis of tracheoesophageal fistula in patients receiving positive pressure ventilation.

Acquired tracheo-oesophageal fistula following tracheal intubation in a burned patient

A 27-year old male sustained a 60 per cent TBSA burn with inhalation injury following a road traffic accident. He developed respiratory distress on day 3 postburn, and was intubated and ventilated. He was noted to have greenish aspirate from his trachea on day 17 of ventilation. He succumbed from sepsis and died on day 21 post injury. At post-mortem, a large tracheo-oesophageal fistula (TOF) was found at the level of the cuff of the nasotracheal tube.

Management of acquired nonmalignant tracheoesophageal fistula

Acquired, nonmalignant tracheoesophageal fistula is an uncommon and difficult problem to manage. The most common cause is a complication of endotracheal or tracheostomy tubes. Most are diagnosed while patients still require mechanical ventilation. We use a conservative approach until patients are weaned from ventilation. A tracheostomy tube is placed so that the balloon rests below the fistula, if possible, to prevent contamination of the tracheobronchial tree. A gastrostomy tube is placed for drainage and a separate jejunostomy tube for nutrition. Single-stage repair is done after the patient is weaned from mechanical ventilation. Esophageal diversion is rarely required. We have performed 41 operations on 38 patients. Simple division and closure of the fistula was done in 9 patients and tracheal resection and reconstruction in the remainder. The esophageal defect was closed in two layers and a viable strap muscle interposed between the two suture lines. There were four deaths (10.9%). There were three recurrent fistulas and one delayed tracheal stenosis. All were successfully managed. Of the 34 surviving patients, 33 aliment themselves orally and 32 breathe without the need for a tracheal appliance.