Possibilities and Results of Surgical Treatment of Benign Tracheoesophageal Fistula

Česká verzia

Authors: T. Krajč; M. Janík; M. Lučenič; R. Benej; S. Haruštiak
Authors place of work: Klinika hrudníkovej chirurgie SZU a FNsP Bratislava, Slovenská republika prednosta prof. MUDr. Svetozár Haruštiak, CSc.
Published in the journal: Rozhl. Chir., 2010, roč. 89, č. 8, s. 478-489.
Category: Monothematic special - Original

Summary

Aim:
Review of literature and a single-institution retrospective analysis of possibilities and results of various surgical techniques in treatment of benign tracheoesophageal fistula (TEF).

Material and methods:
Between 1995 and 2010, 26 patients with benign tracheoesophageal fistula of various etiology underwent surgical treatment at the Department of Thoracic Surgery of Slovak Medical University and Faculty Hospital in Bratislava. The majority of patients had a postintubation TEF (21 cases), two fistulas were of traumatic origin, one iatrogenic, one congenital with adulthood manifestation and one tracheo-neoesophageal (TNEF) following an esophagectomy for carcinoma via extended cervical approach with lymphadenectomy and sternal retraction adpoted from transcervical extended mediastinal lymphadenectomy. We review the possible means of surgical treatment of TEF, of which we most frequently used segmental tracheal resection with end-to-end anastomosis and a non-overlying suture of the esophageal defect without muscle flap interposition (16 patients), transsection of the fistula with muscular flap interposition via cervical (2 patients) or transthoracic (1 patient) approach; or a T-tube insertion with (1 patient) or without (5 patients) discision and suture of the TEF. The only tracheo-neoesophageal fistula in our experience had been treated by neoesophagectomy, covering of tracheal defect by intercostal muscle flap and cervical esophagostomy.

Results:
Short- and long-term results of TEF treatment in our institution have been favourable, with perioperative mortality of 3.8% (the patient with tracheo-neoesophageal fistula). Morbidity included 1 partial tracheal anastomotic dehiscence, 3 temporary left recurrent nerve palsies, temporary deglutition disorders (15 patients), tracheal anastomosis granulations in 1 patient and 2 wound infections. Out of 26 patients 15 (58%) are being followed-up on a regular basis, all with good (12 patients) or satisfactory (3 patients) functional results.

Conclusion:
In the paper we analyze the advantages and disadvantages of various techniques and their alternatives in the treatment of TEF. As the most reliable and suitable solution for patients with postintubation TEF, breathing spontaneously and with acceptable nutritional status, we favour segmental trachea resection with end-to-end anastomosis and esophageal suture without muscle interposition, regardless of presence of concomitant tracheal stenosis. Fistulae of other etiologies require diverse approaches, especially tailored with respect to their location. Management of tracheo-neoesophageal fistula following esophagectomy for carcinoma is extremely demanding. Therefore, it is crucial to adhere to basic rules of prevention of such benign but potentially fatal entities as TEF and TNEF.

Key words:
benign tracheoesophageal fistula – tracheo-neoesophageal fistula – surgical treatment

Zdroje

1. Grillo, H. C. Acquired tracheoesophageal and bronchoesophageal fistula. In: H.C. Grillo (zostavovateľ) Surgery of the trachea and bronchi. Hamilton, Ontario, USA: BC Decker Inc, 2004, s. 341–356.

2. Fiala, P., Cernohorsky, S., Cermak, J., et al. Tracheal stenosis complicated with tracheoesophageal fistula. European Journal of Cardio-Thoracic Surgery, 25, 2004, č. 1, s. 127–130.

3. Harley, H. R. Ulcerative tracheo-oesophageal fistula during treatment by tracheostomy and intermittent positive pressure ventilation. Thorax, 27, 1972, č. 3, s. 338–352.

4. Macchiarini, P., Verhoye, J.-P., Chapelier, A., et al. Evaluation and outcome of different surgical techniques for postintubation tracheoesophageal fistulas. Journal of Thoracic and Cardiovascular Surgery, 119, 2000, č. 2, s. 268–276.

5. Wychulis, A. R., Ellis, F. H., Jr., Andersen, H. A. Acquired Nonmalignant Esophagotracheobronchial Fistula: Report of 36 Cases. JAMA: The Journal of the American Medical Association, 196, 1966, č. 2, s. 117–122.

6. Black, R. J. Congenital tracheo-oesophageal fistula in the adult. Thorax, 37, 1982, č. 1, s. 61–63.

7. Ashour, M. Recurrence of tracheo-oesophageal fistula 32 years after primary repair. Thorax, 41, 1986, č. 1, s. 76–77.

8. Rajesh, P. B., Goiti, J. J. Late onset tracheo-oesophageal fistula following a swallowed dental plate. Eur. J. Cardiothorac. Surg., 7, 1993, č. 12, s. 661–662.

9. Kanne, J. P., Stern, E. J., Pohlman, T. H. Tracheoesophageal Fistula from a Gunshot Wound to the Neck. American Journal of Roentgenology, 180, 2003, č. 1, s. 212.

10. O_ordan, J. M., Hickey, N., Ilinski, O., et al. Successful early repair of a traumatic tracheoesophageal fistula after blunt chest trauma. J. Thorac. Cardiovasc. Surg., 132, 2006, č. 6, s. 1495–1496.

11. Stanbridge, R. D. Tracheo-oesophageal fistula and bilateral recurrent laryngeal nerve palsies after blunt chest trauma. Thorax, 37, 1982, č. 7, s. 548–549.

12. Cherveniakov, A., Tzekov, C., Grigorov, G. E., et al. Acquired benign esophago-airway fistulas. European Journal of Cardio-Thoracic Surgery, 10, 1996, č. 9, s. 713–716.

13. Bartels, H. E., Stein, H. J., Siewert, J. R. Respiratory management and outcome of non-malignant tracheo-bronchial fistula following esophagectomy. Dis. Esophagus, 11, 1998, č. 2, s. 125–129.

14. Bartels, H. E., Stein, H. J., Siewert, J. R. Tracheobronchial lesions following oesophagectomy: prevalence, predisposing factors and outcome. Br. J. Surg., 85, 1998, č. 3, s. 403–406.

15. Buskens, C. J., Hulscher, J. B. F., Fockens, P., et al. Benign tracheo-neo-esophageal fistulas after subtotal esophagectomy. Annals of Thoracic Surgery, 72, 2001, č. 1, s. 221–224.

16. Zielinski, M. Transcervical extended mediastinal lymphadenectomy: results of staging in two hundred fifty-six patients with non-small cell lung cancer. J. Thorac. Oncol., 2, 2007, č. 4, s. 370–372.

17. Serrano, N., Mora, M. L. The breathing-bag sign in the diagnosis of tracheoesophageal fistula in patients receiving mechanical ventilation. Chest, 117, 2000, č. 4, s. 1217–1218.

18. Haruštiak, S. Zkušenosti s chirurgickou léčbou trachey. In: M. Hájek, J. Drábková, S. Haruštiak, M. Marel a J. Vomela (zostavovatelia), Kritická onemocnění průdušnice a jejich léčení. Praha: Grada Publishing, 2000, s. 97–109.

19. Bardini, R., Radicchi, V., Parimbelli, P., et al. Repair of a recurrent benign Tracheoesophageal fistula with a Gore-Tex membrane. Annals of Thoracic Surgery, 76, 2003, č. 1, s. 304–306.

20. Scappaticci, E., Ardissone, F., Baldi, S., et al. Closure of an iatrogenic tracheo-esophageal fistula with bronchoscopic gluing in a mechanically ventilated adult patient. Ann. Thorac. Surg., 77, 2004, č. 1, s. 328–329.

21. Bartlett, R. H. A procedure for management of acquired tracheoesophageal fistula in ventilator patients. J. Thorac. Cardiovasc. Surg., 71, 1976, č. 1, s. 89–95.

22. Galan, G., Tarrazona, V., Soliveres, J., et al. Tracheoplasty in a large tracheoesophageal fistula. Ann. Thorac. Surg., 68, 1999, č. 3, s. 1071–1072.

23. He, J., Chen, M., Shao, W., et al. Surgical management of huge tracheo-oesophageal fistula with oesophagus segment in situ as replacement of the posterior membranous wall of the trachea. European Journal of Cardio-Thoracic Surgery, 36, 2009, č. 3, s. 600–602.

24. Jougon, J., Couraud, L. Esophageal patching for an unsuturable tracheoesophageal fistula. European Journal of Cardio-Thoracic Surgery, 14, 1998, č. 4, s. 431–433.

25. Landreneau, R. J., Hazelrigg, S. R., Boley, T. M., et al. Management of an extensive tracheoesophageal fistula by cervical esophageal exclusion. Chest, 99, 1991, č. 3, s. 777–780.

26. Utley, J. E., Dillon, M. L., Todd, E. P., et al. Giant tracheoesophageal fistula: management by esophageal diversion. J. Thorac. Cardiovasc. Surg., 75, 1978, č. 3, s. 373–377.

27. Chappell, V. L., Heck, H. A. jr. Repair of large, iatrogenic, tracheo-esophageal fistulae. Ann. Thorac. Surg., 83, 2007, č. 2, s. 705–706.

28. Camargo, J. J., Machuca, T. N., Camargo, S. M., et al. Surgical treatment of benign tracheo-oesophageal fistulas with tracheal resection and oesophageal primary closure: is the muscle flap really necessary? European Journal of Cardio-Thoracic Surgery, 37, 2010, č. 3, s. 576–580.

29. Joynt, G. M., Chui, P. T., Mainland, P., et al. Total intravenous anesthesia and endotracheal oxygen insufflation for repair of tracheoesophageal fistula in an adult. Anesthesia & Analgesia, 82, 1996, č. 3, s. 661–663.

30. Maseda, E., Diaz-Agero, P., Suarez, L., et al. Tracheal intubation through tracheoesophageal fistula. Anesthesia & Analgesia, 80, 1995, č. 2, s. 422–423.

31. Krajc, T., Janik, M., Benej, R., et al. Urgent segmental resection as the primary strategy in management of benign tracheal stenosis. A single center experience in 164 consecutive cases. Interact Cardiovasc. Thorac. Surg., 9, 2009, č. 6, s. 983–989.

32. Kron, I. L., Johnson, A. M., Morgan, R. F.: Gastrotracheal fistula: a late complication after transhiatal esophagectomy. Ann. Thorac. Surg., 47, 1989, č. 5, s. 767–768.

33. Maruyama, K., Motoyama, S., Okuyama, M., et al. Esophagotracheal fistula caused by gastroesophageal reflux 9 years after esophagectomy. World J. Gastroenterol., 13, 2007, č. 5, s. 801–803.

34. Fujita, H., Kawahara, H., Hidaka, M., et al. An experimental study on viability of the devascularized trachea. Jpn. J. Surg., 18, 1988, č. 1, s. 77–83.

35. Song, S.-W., Lee, H.-S., Kim, M. S., et al. Repair of gastrotracheal fistula with a pedicled pericardial flap after Ivor Lewis esophagogastrectomy for esophageal cancer. J. Thorac. Cardiovasc. Surg., 132, 2006, č. 3, s. 716–717.

36. Kalmar, K., Molnar, T. F., Morgan, A., et al. Non-malignant tracheo-gastric fistula following esophagectomy for cancer. European Journal of Cardio-Thoracic Surgery, 18, 2000, č. 3, s. 363–365.

37. Buskens, C. J., van Coevorden, F., Obertop, H., et al. Disturbed anastomotic healing after esophagectomy: a novel treatment of a benign tracheo-neo-esophageal fistula. Dig. Surg., 19, 2002, č. 2, s. 88–91.

38. Devbhandari, M. P., Jain, R., Galloway, S., et al. Benign gastro-bronchial fistula – an uncommon complication of esophagectomy: case report. BMC Surg., 5, 2005, s. 16.

39. Vasquez, R. E., Landay, M., Kilman, W. J., et al. Benign esophagorespiratory fistulas in adults. Radiology, 167, 1988, č. 1, s. 93–96.

40. Zacharias, J., Genc, O., Goldstraw, P. Congenital tracheoesophageal fistulas presenting in adults: presentation of two cases and a synopsis of the literature. J. Thorac. Cardiovasc. Surg., 128, 2004, č. 2, s. 316–318.

41. Garand, S. A., Kareti, L. R., Dumont, T. M., et al. Thoracoscopic repair of tracheoesophageal fistula in a septuagenarian. Ann. Thorac. Surg., 81, 2006, č. 5, s. 1899–1901.

42. Rabenstein, T., Boosfeld, C., Henrich, R., et al. First use of ventricular septal defect occlusion device for endoscopic closure of an esophagorespiratory fistula using bronchoscopy and esophagoscopy. Chest, 130, 2006, č. 3, s. 906–909.

43. Reed, W. J., Doyle, S. E., Aprahamian, C. Tracheoesophageal Fistula After Blunt Chest Trauma. Annals of Thoracic Surgery, 59, 1995, č. 5, s. 1251–1256.

44. Weber, S. M., Schurr, M. J., Pellett, J. R. Delayed Presentation of a Tracheoesophageal Fistula After Blunt Chest Trauma. Annals of Thoracic Surgery, 62, 1996, č. 6, s. 1850–1852.