Tracheoesophageal Fistula

There are three varieties, acquired, malignant and congenital.

Acquired Nonmalignant Tracheoesophageal Fistula Acquired nonmalignant tracheoesophageal fistulas may rise from pressure erosion at the site of an endotracheal tube. This is the most common cause at the present time and usually occurs in the presence of an esophageal feeding tube. However, in the past granulomatous mediastinal infections and trauma were more important. The incidence of this type of acquired tracheoesophageal fistula secondary to endotracheal cuff erosion is starting to decline because of the use of high volume low pressure cuffed endotracheal tubes. If the tracheoesophageal fistula occurs while the patient is still endotracheally intubated, reconstruction is not performed. Instead, the endotracheal tube is replaced with a low pressure cuff which is placed, if possible, as a tracheostomy below the level of the fistula. A gastrostomy may be performed to keep the stomach empty to prevent reflux, and a feeding jejunostomy is placed. The feeding tube through the esophagus is removed. When the patient is able to be extubated, the benign tracheoesophageal fistula is approached through a oblique sternocleidomastoid type incision on the left side. Another approach is a collar incision. A portion of the trachea usually needs to be resected with intubation of the distal trachea across the operative field or conversely using high frequency jet ventilation. The esophagus is repaired and then the trachea is reapproximated and re-anastomosed using 4-0 Vicryl in an interrupted fashion.

Intra-thoracic tracheoesophageal fistulas are very rare, and the best approach is a right thoracotomy. The safest interposition is a intercostal muscle flap. For the cervical trachea, the sternal hyoid muscle is detached and sutured over the esophageal closure to an anastomosis of the trachea. Tracheal resection in the intrathoracic portion is usually not required since circumferential injuries with a cuff usually do not occur here. Sometimes additional tissue can be "stolen" away from the esophagus to close a large defect in the membraneous wall of the trachea, and this is perferred over a resection.

Malignant Tracheoesophageal Fistula

This usually results from malignant esophageal tumors eroding into the trachea. Eighty percent of these patients are dead from their cancer within 3 months, even when treated. It should be noted that all untreated patients, however, die miserably from repeated aspirations and some attempt at palliation is usually indicated. The two main treatment methods include esophageal intubation and surgical exclusion with bypass procedures. These accomplish the goals of excluding the fistula and restoring continuity of the esophagus. Esophageal intubation is effective for a period of time by sealing the fistula and relieving the obstruction temporarily. Diversion may be performed by cervical esophagostomy and gas-trostomy. In esophageal exclusion with stomach or colonic bypass, the esophagus is stapled proximal and distal to the fistula and a bypass is performed using a substernal stomach or colon approach. Alternatively, the esophageal exclusion could be performed and a cervical esophagostomy performed.

The role of radiation therapy is limited to de novo tracheoesophageal fistulas. On the other hand, if the patient has already had radiation therapy, the chance of

Fig 24.6a. Incidence of the most common forms of tracheoesophageal fistula. A=85%; B=8%; C=4%. Reprinted with permission from Shields TW. General Thoracic Surgery, 4th ed. Fig. 79-5.

Acquired Tracheoesophageal Fistula

Fig 24.6b. Standard initial management of the most common type of tracheoesophageal fistula with proximal esophageal decompression and gastrostomy in preparation for definitive surgery. Reprinted with permission from Shields TW. General Thoracic Surgery, 4th ed. Fig. 79-2.

any success with further radiation is nil.

Congenital Tracheoesophageal Fistula

This is shown in Figure 24.6 a-b. The most common variety involves the esoph-ageal atresia proximally with a distal esophageal fistula. This occurs over 85% of the time with other less common variants being the proximal and distal esophageal atresia without a fistula or the H-type fistula. When a congenital tracheoesophageal is suspected, an orogastric tube should be passed and the diagnosis confirmed since the tube cannot be passed further than the end of the proximal pouch. Once the diagnosis is made of the most common variety of the tracheoesophageal fistula, the proximal pouch is decompressed with the sump catheter. The child is placed prone or with the head at 45° to prevent aspiration. It is important to establish the status of the child as an operative candidate according to the Waterston criteria. The Waterston A category is an infant with a birth weight greater than 2500 grams and no evidence of pneumonia and no major anomalies. Group B is an infant with a birth weight of 1800-2500 grams who may have pneumonia but has no major associated abnormalities. In group C, the infant is less than 1800 grams and does have major associated anomalies. Children who have Waterston A classification are candidates for immediate repair, at which time they undergo a right thoracotomy and primary repair of the trachea and esophagus with ligation and transection of the fistula. Children classified as Waterston B can be managed by delayed primary repair. There is decompression of the proximal esophagus with a sump catheter and the patient undergoes a gastrostomy to prevent further reflux into the trachea. Once the pneumonia has cleared, primary repair is performed. Children of the Waterston C are very difficult to manage and their treatment must be individualized, and the most serious life-threatening disease taken care of first if feasible. Sometimes it may be difficult to mobilize the proximal and distal esophagus enough to achieve primary repair. In this case an esophageal myotomy may be necessary to increase the length of the proximal pouch to relieve tension.

Suggested Reading

1. Grillo HC. Surgery of the trachea. In: Current Problems in Surgery. Chicago: Year Book Medical Publishers, 1970.

2. Perelman MI, Korolevo N. Surgery of the trachea. World J Surgery 1980; 4:583.

3. Grillo HC. Tracheal tumors. Surgical Management. Ann Thoracic Surg 1978; 26:112.

4. Pearson FG, Todd TRJ, Cooper JD. Experience with primary neoplasms of the trachea and carina. J Thoracic Cardiovasc Surg 1984, 88:511-518.

5. Grillo HC. Surgical Management of post-intubation tracheal injuries. J Thoracic Cardiovasc Surg 1979, 78:860-875.

Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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