Tracheoesophageal Fistula: Its Types And Treatment
A tracheoesophageal fistula is a link between trachea and esophagus. Due to this liquids and foods can be aspirated into the lungs.
The devastating pulmonary complications from tracheoesophageal fistulas can be minimized by a few simple maneuvers. A new tracheostomp tube should be placed if possible, so that the balloon is below the fistula to minimize soiling of the tracheobronchial tree. A separate jejunostomy tube is inserted for nutritional purposes. These measures usually obviate the need for esophageal diversion with ligation of the gastroesophageal junction. Because mechanical ventilation after tracheal reconstruction is associated with a high incidence of anastomotic dehiscence or restenosis, a conservative approach is used until the patient is weaned. Esophageal diversion complicates and lengthens management of these patients.
It should be reserved for cases where soilage of the tracheobronchial tree continues despite conservative measures or for supracarinal fistulas that cannot be controlled otherwise. Once the patient is weaned from mechanical ventilation, single-stage repair can then be undertaken without the risks of postoperative ventilation. Most tra- cheoesophageal fistulas require tracheal resection because of circumferential injury to the trachea at the inciting cuff site or because of the size of the fistula.
Types of tracheoesophageal fistula
Type A = pure esophageal atresia.
Type B = esophageal atresia with proximal tracheoesophageal fistula.
And, Type C = esophageal atresia with distal tracheoesophageal fistula.
Type D = esophageal atresia with proximal and distal tracheoesophageal fistula.
Type E = H-type tracheoesophageal fistula without esophageal atresia.
Tracheoesophageal fistula radiology
tracheoesophageal fistula radiology
A sudden increase in tracheal secretions is often the first sign that a tracheoesophageal fistula is present. Plain chest radiographs may demonstrate the esophagus dilated with air distal to the fistula. This finding, although often subtle, is pathognomonic for tracheoesophageal fistula. Barium contrast studies usually demonstrate the fistula. Complete radiographic examination of the trachea is also done. Bronchoscopy and esophagoscopy are helpful to demonstrate and identify its exact location. Instillation of methylene blue or air into the esophagus while observing the trachea through a bronchoscope may identify small fistulas. Rigid bronchoscopy is essential to determine the extent of airway injury and to determine whether resection and reconstruction of the trachea is required.
Tracheoesophageal fistula treatment
SMALL FISTULA AND NORMAL TRACHEA
The small tracheoesophageal fistula that does not require tracheal resection poses unique technical problems.
Exposure through the neck is often limited, especially when the fistula is located distally. More importantly, the recurrent laryngeal nerve on the side of exposure is in jeopardy of being injured. Local inflammation may make identification of the nerve difficult. In these circumstances, it is best to identify the nerves at a location remote from the fistula. The nerve should be elevated with the trachea during exposure of the fistula. Care should be taken to avoid retractor injuries to the recurrent nerve.
The fistula is identified and divided. The inner layer consists of esophageal mucosa. interrupted 4-0 silk sutures can be given. The esophageal muscle is then closed over the mucosal layer. A strap muscle is pedicled to buttress and separate the tracheal and esophageal suture lines. This minimizes the risk of recurrent fistula.
If concern exists about the degree of narrowing of the trachea, a small amount of esophageal mucosa can be left with the tracheal side of the fistula. This can then be used in the closure of the tracheal defect to minimize tracheal narrowing.
LARGE DEFECT WITH CIRCUMFERENTIAL TRACHEAL DAMAGE
The fistula that requires tracheal resection, although technically more complicated, provides much better exposure. Circumferential dissection above and below the fistula should be very close to the trachea to avoid injury Operative Technique.
The principles of patient management before definitive repair have been delineated. This approach allows pulmonary sepsis to be controlled, nutrition to be optimized, and, most importantly, mechanical ventilation to be ended. The principles of tracheal surgery need to be closely followed because many of the cases are reoperations or associated with more than the usual amount of inflammation Most postintubation tracheoesophageal fistulas may be corrected through a low collar incision, oftentimes including the tracheostomy stoma if present. Partial division of the sternum to just below the angle of Louis gives exposure of the trachea to carinal level. A right lateral thoracotomy through the fourth interspace is preferable for fistulas at or just above the carina or if a previous operation was done transthoracically.
The nerves are allowed to fall laterall resection of the damaged portion of the trachea gives excellent exposure of the esophageal defect. It is essential to separate the esophageal suture line with a strap muscle to help prevent recurrent tracheoesophageal fistula. Narrowing of the esophagus to this degree is well tolerated. Esophageal dilation may be required postoperatively. Lateral traction sutures of 2-0 Vicryl are used and left in place. Absorbable suture material has dramatically reduced the incidence of suture line granulomas. Anastomotic tension must be scrupulously avoided. Resection of excessive amounts of trachea must be avoided. A Montgomery suprahyoid laryngeal release may be needed if flexion of the neck is not sufficient to minimize anastomotic tension. The anastomosis should be covered by reapproximation of the thyroid isthmus or strap muscle to avoid contamination by the tracheostomy tube.
It is possible to close longitudinally the posterior defect in the membranous tracheal wall, borrowing some adjacent esophageal wall if needed. This limits the amount of trachea to be resected and allows reconstruction that otherwise might not be possible. This presumes the cartilaginous tracheal wall is healthy.
For those situations where the length of tracheal dam- age exceeds the limits of reconstruction, it is still worth- while to repair the fistula and buttress the closure with strap muscle. The airway can be maintained by a tracheal T tube. Oral alimentation is then possible, thus avoiding the need for permanent feeding tubes.
Management of Tracheal Defect
This can be done because of the presence of tracheal stenosis with full thickness circumferential dam-age at the level of the cuff or stoma or when the defect in the membranous tracheal wall was too large for direct closure.