Operative technique
Endoscopic management of recurrent tracheoesophageal fistula

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Abstract

Rational

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.

Section snippets

Methods

With approval from the institutional review board, a retrospective chart review of all patients undergoing endoscopic closure of RTEF (2003-2007) was performed at a single tertiary care pediatric institution. Patients referred to our institution were identified by pediatric otolaryngology and general surgery teams based on clinical suspicion and symptoms after open tracheoesophageal fistula closure. Esophograms were conducted on each patient to assist in diagnosis (Fig. 1A). Patient

Results

Four patients after primary tracheoesophageal repair underwent endoscopic RTEF obliteration at our institution between 2003 and 2007. Each patient had undergone prior repair of a proximal esophageal atresia with a distal TEF. Average time to discovery was 9.5 months (range, 2-19 months). Presenting symptoms were variable but consistent with persistent airway complaints after primary repair (Table 1). Recurrent wheezing, coughing and cyanosis with feeds, and evidence of persistent pnuemonitis

Discussion

Five anatomic variations of TEF exist. The most common presentation is distal TEF with proximal esophageal atresia (84%-88%). Repairs are performed shortly after birth with a relative recurrence rate of 3% to 20% depending upon surgical technique and TEF type [1], [3], [4], [21], [22], [23], [24]. Symptomatic clues of RTEF include coughing, wheezing, and cyanosis with feeding. However, subtle airway complaints or signs of persistent pnuemonitis despite antibiotic and reflux management most

Conclusion

Recurrent tracheoesophageal fistula after primary TEF repair is a rare but difficult complication. Increased morbidity and mortality rates have been reported during open revision cases of RTEF. The advent of endoscopic techniques for both pediatric otolaryngologists and general surgeons has provided a potential avenue for reducing perioperative morbidity and recurrence after open RTEF repair. Various endoscopic techniques have been used. Both the use of tissue adhesives and denuding the fistula

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