Tracheoesophageal fistula in a COVID-19 patient

Not only acute respiratory failure: COVID-19 and the post-intubation/tracheostomy upper airways lesions†

Background

An increasing number of patients have been subjected to prolonged invasive mechanical ventilation due to COVID-19 infection, leading to a significant number of post-intubation/tracheostomy (PI/T) upper airways lesions. The purpose of this study is to report our early experience in endoscopic and/or surgical management of PI/T upper airways injuries of patients surviving COVID-19 critical illness.

Materials and Methods

We prospectively collected data from patients referred to our Thoracic Surgery Unit from March 2020 to February 2022. All patients with suspected or documented PI/T tracheal injuries were evaluated with neck and chest computed tomography and bronchoscopy.

Results

Thirteen patients (8 males, 5 females) were included; of these, 10 (76.9%) patients presented with tracheal/laryngotracheal stenosis, 2 (15.4%) with tracheoesophageal fistula (TEF) and 1 (7.7%) with concomitant TEF and stenosis. Age ranged from 37 to 76 years. Three patients with TEF underwent surgical repair by double layer suture of oesophageal defect associated with tracheal resection/anastomosis (1 case) or direct membranous tracheal wall suture (2 cases) and protective tracheostomy with T-tube insertion. One patient underwent redo-surgery after primary failure of oesophageal repair. Among 10 patients with stenosis, two (20.0%) underwent primary laryngotracheal resection/anastomosis, two (20.0%) had undergone multiple endoscopic interventions before referral to our Centre and, at arrival, one underwent emergency tracheostomy and T-tube positioning and one a removal of a previously positioned endotracheal nitinol stent for stenosis/granulation followed by initial laser dilatation and, finally, tracheal resection/anastomosis. Six (60.0%) patients were initially treated with rigid bronchoscopy procedures (laser and/or dilatation). Post-treatment relapse was experienced in 5 (50.0%) cases, requiring repeated rigid bronchoscopy procedures in 1 (10.0%) for definitive resolution of the stenosis and surgery (tracheal resection/anastomosis) in 4 (40.0%).

Conclusions

Endoscopic and surgical treatment is curative in the majority of patients and should always be considered in PI/T upper airways lesions after COVID-19 illness.

The surgical approach of late-onset tracheoesophageal fistula in a tracheostomized COVID-19 patient

In the COVID-19 era the tracheal complications due to prolonged mechanical ventilation have significantly increased. Acquired tracheoesophageal fistula is one of those in ventilated COVID-19 patients. Thus, the knowledge of their management in such fragile patient is crucial. We report a case of tracheoesophageal fistula in a 56-year-old female under prolonged mechanical ventilation for COVID-19 bilateral pneumonia and discuss its management. A surgical approach was proposed. By a collar-shaped transverse cervicotomic access, we transected the trachea at level of fistula en-bloc with the tracheostoma. The esophageal lesion was longitudinally repaired in two-layers. Protective left strap muscle was sandwiched between esophagus and trachea. The tracheal end-to-end anastomosis was completed without a re-tracheostoma. Even if surgical approach of tracheoesophageal fistula in COVID-19 patients has not been tested before, surgery remains the treatment of choice according to the multidisciplinary board.

Tracheoesophageal fistulas in coronavirus disease 2019 pandemic: A case report

BACKGROUND

Tracheoesophageal fistulas (TEFs) can be described as a pathological communication between the trachea and the esophagus. According to their origin, they may be classified as benign or malignant. Benign TEFs occur mostly as a consequence of prolonged mechanical ventilation, particularly among patients exposed to endotracheal cuff overinflation. During the severe acute respiratory syndrome coronavirus 2 virus pandemic, the amount of patients requiring prolonged ventilation rose, which in turn increased the incidence of TEFs.

CASE SUMMARY

We report the cases of 14 patients with different comorbidities such as being overweight, or having been diagnosed with diabetes mellitus or systemic hypertension. The most common symptoms on arrival were dyspnea and cough. In all cases, the diagnosis of TEFs was made through upper endoscopy. Depending on the location and size of each fistula, either endoscopic or surgical treatment was provided. Eight patients were treated endoscopically. Successful closure of the defect was achieved through over the scope clips in two patients, while three of them required endoscopic metal stenting. A hemoclip was used to successfully treat one patient, and it was used temporarily for another patient pended surgery. Surgical treatment was performed in patients with failed endoscopic management, leading to successful defect correction. Two patients died before receiving corrective treatment and four died later on in their clinical course due to infectious complications.

CONCLUSION

The incidence of TEFs increased during the coronavirus disease 2019 pandemic (from 0.5% to 1.5%). We believe that endoscopic treatment should be considered as an option for this group of patients, since evidence reported in the literature is still a growing area. Therefore, we propose an algorithm to lead intervention in patients presenting with TEFs due to prolonged intubation.

Tracheo-esophageal fistula and pleural empyema in the course of SARS-CoV-2 infection-A case report

We report a 49-year-old patient with COVID-19 who developed lung abscess, pleural empyema, and tracheo-esophageal fistula. He underwent cervicotomy, segmental tracheal resection, esophageal-tracheal fistula excision, and suturing the esophagus, and a classic thoracotomy was performed. Despite the severe infection, the patient was discharged home after successful surgical treatment.

Analysis of the Application Value of Different Esophagography Techniques in the Diagnosis of H-Type Tracheoesophageal Fistula in Neonates

Objective

The study aimed to analyse the detection rates of the triple-lumen double-balloon catheter technique and conventional esophagography in diagnosing H-type tracheoesophageal fistula (H-TEF) in neonates.

Methods

The data of 8 neonates diagnosed with H-TEF by surgery in the researchers' hospital between January 2015 and January 2022 were collected. We compared the detection (true positive) rates of H-TEF by the triple-lumen double-balloon catheter technique, conventional esophagography, and multidetector row spiral CT.

Results

Before surgery, conventional esophagography was applied in all 8 cases, of which the H-TEF diagnosis was confirmed in 5 cases and TEF was suspected in 3 cases. The triple-lumen double-balloon catheter technique was employed in 5 cases, of which 4 were confirmed with H-TEF and 1 was suspected with TEF. Multidetector row spiral CT was performed in 4 cases, and 1 case was confirmed with H-TEF, while no fistula was observed in the other 3 cases. The triple-lumen double-balloon catheter technique yielded a 100% detection rate, while conventional esophagography revealed a 62.5% rate and multidetector row spiral CT showed a 25% rate. By comparative analysis, the true positive rates (TPRs) of the triple-lumen double-balloon catheter technique and conventional esophagography were not significantly different (P=0.118). No significant differences were recorded in TPRs between conventional esophagography and multidetector row spiral CT (P=0.221). However, the triple-lumen double-balloon catheter technique had a significantly higher TPR than multidetector row spiral CT (P=0.118).

Conclusion

To diagnose congenital H-TEF in neonates, conventional esophagography is a highly valuable yet inconsistently reliable method and the diagnostic value of CT is relatively limited. The triple-lumen double-balloon catheter technique boasts a significantly valuable application for H-TEF diagnosis. Being simple, economical, and effective, it barely requires state-of-the-art facilities, and no complications have occurred during its clinical practice. These advantages justify a possible wider application of the triple-lumen double-balloon catheter technique in clinical practice.