Tracheoesophageal fistula after esophageal atresia repair: recurrent, missed or acquired

Abstract

Esophageal atresia (EA) is a common congenital anomaly of pediatric surgical practice.Tracheoesophageal fistula (TEF) is defined as congenital fistulous connection between esophagus and airway.All newborns with EA need immediate surgical repair of this anomaly. As the survival has reached to 95%, the long-term consequences of TEF have become the focus of interest. The main complications of EA repair are classified as early complications including anastomotic leak, stricture, recurrent TEF (recTEF) and late complications including gastroesophageal reflux, esophageal dysmotility, tracheomalacia and respiratory disorders. TEFs seen after EA repair are the most challenging complication for both patient and the surgeon. These fistulas can occur after EA repair because of the recanalization of ligated original TEF called recTEF, a de novo fistula with different location called acquired TEF (acqTEF) or a second congenital fistula missed at the primary surgery called missed TEF (mTEF). Overall, incidence of fistula recurrence is between 5-10%. The well-described risk factors for TEF recurrences are inadequate ligation of original TEF, anastomotic complications including leak, stricture and ischemia, tracheal injuries at the primary repair, and juxtapositioning of esophageal and tracheal suture lines. The clinical presentation of all types of fistulas is similar. Thus, the diagnosis of all these fistulas is challenging. Even, all patients having coughing, chocking or recurrent respiratory tract infections after EA repair should be investigated for the presence of TEF recurrence. In addition, the management of each type of fistula requires different approaches and can be technically demanding for most cases. Although surgical management is mostly inevitable in the management of recTEF, medical observation may be a choice for the management of acqTEFs since there is a possibility of spontaneous healing. Despite the advanced surgical technique, the risk for secondary recurrences, increased morbidity and even mortality are still exists. Therefore, this review will focus on all of the aspects of TEFs seen after EA repair.

Missed Proximal Tracheoesophageal Fistula (TEF) in a Neonate with Type D Esophageal Atresia

“…Repair of a proximal fistula is mostly recommended via a cervical approach, although thoracoscopic approaches have also been reported. [8,11] This case report illustrates the potential difficulties to diagnose type D EA. In our case, it was diagnosed coincidentally prior to developing clinical symptoms suggestive of a recurrent or missed proximal fistula.…”

“…coughing and respiratory incidents). [8,10] The diagnostic laryngotracheobronchoscopy prior to the first surgical procedure was performed by an ENT staff member who is experienced in trachea-bronchoscopies and esophageal atresia. It did not show abnormalities in the proximal trachea, and esophagoscopy was not performed.…”

“…9,10 The clinical diagnosis of recurrent or missed fistula is challenging as most patients also suffer from gastroesophageal reflux or tracheomalacia, symptoms compatible with TEF (e.g., coughing and respiratory incidents). 8,10 The diagnostic laryngotracheobronchoscopy prior to the first surgical procedure was performed by an ear, nose, and throat (ENT) staff member who is experienced in tracheobronchoscopies and EA. It did not show abnormalities in the proximal trachea, and esophagoscopy was not performed.…”

“…Repair of a proximal fistula is mostly recommended via a cervical approach, although thoracoscopic approaches have also been reported. 8,11 Fig. 2 Preoperative bronchoscopy prior to the second surgical procedure showed only a small dimple in the proximal trachea (pointed out by the arrow), without a clear lumen of a fistula.…”

“… 9 10 The clinical diagnosis of recurrent or missed fistula is challenging as most patients also suffer from gastroesophageal reflux or tracheomalacia, symptoms compatible with TEF (e.g., coughing and respiratory incidents). 8 10 …”