Asian Cardiovasc Thorac Ann 2008;16:318-320
© 2008 Asia Publishing EXchange Ltd
Early Repair of Acquired Tracheoesophageal Fistula
Chou-Ming Yeh, MD,
Chia-Man Chou, MD1
Division of Thoracic Surgery, Taichung Hospital
1 Department of Surgery Taichung Veterans General Hospital Taichung, Taiwan
For reprint information contact: Chia-Man Chou, MD Tel: 886 4 2359 2525 Ext. 5182 Fax: 886 4 237 41323 Email: cmchou{at}vghtc.gov.tw, Department of Surgery, Taichung Veterans General Hospital, 160, Sec 3, Chung-Kang Road, Taichung, Taiwan.
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ABSTRACT
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We report early direct repair of a cuff-related tracheoesophageal fistula in a 30-year-old alcoholic man with diabetic ketoacidosis who fell unconscious and was ventilated via an endotracheal tube. He was successfully weaned from the ventilator 1 week after the operation.
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INTRODUCTION
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Tracheoesophageal fistula (TEF) is a congenital or acquired connection between the trachea and esophagus, which may occur following prolonged mechanical ventilation via an endotracheal or tracheostomy tube, and often leads to severe and fatal pulmonary complications. It is an uncommon and difficult problem to manage.
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CASE REPORT
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A 30-year-old alcoholic man presented with a 1-month history of general malaise and was admitted to another hospital where diabetic ketoacidosis was diagnosed. He fell unconscious after admission, and endotracheal intubation with mechanical ventilation was instituted. Pneumonia was noted and sputum culture grew Klebsiella pneumonia. Acute respiratory distress developed and he was referred to our hospital due to difficulties in weaning from the ventilator. On arrival, he was in a stupor with a Glasgow coma scale of E4VTM3. A right-sided chest tube was in place due to parapneumonic effusion. Chest radiography showed a hyperinflated cuff over the cervical region (Figure 1
). Physical examination revealed distended abdomen. Panendoscopy confirmed TEF (Figure 2A). The endotracheal tube cuff was passed distal to the fistula, and decompression gastrostomy and feeding jejunostomy were embarked on. Jejunostomy feeding was started on the 5th postoperative day. One month later, the patient’s pulmonary condition became stable, but he still depended on mechanical ventilation. A follow-up operation was carried out for repair of TEF and tracheostomy. A left oblique neck incision was made parallel to the anterior border of the sternocleidomastoid muscle. The fistula was divided, the defects in the trachea and esophagus were identified, and primary repair was undertaken. A tracheostomy was performed for further respiratory care. The patient was successfully weaned from mechanical ventilation 1 week after the operation. Panendoscopy was repeated on the 12th postoperative day and showed the esophageal wound had healed well (Figure 2B). Flexible bronchoscopy revealed the tracheal defect proximal to the tracheostomy tube had also healed well.
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Figure 1. Chest radiograph showing acute respiratory distress changes over both lung fields and a hyperinflated cuff over the cervical region (arrow).
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Figure 2. Panendoscopy (A) preoperatively showing the tracheoesophageal fistula and (B) postoperatively confirming the well-healed esophageal wound.
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DISCUSSION
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Acquired nonmalignant TEF occurs in approximately 0.5%, and malignant TEF in 4.5% and 0.3% of primary malignant esophageal and lung tumors, respectively1. Acquired TEF can occur in individuals of any age, while the elderly are at increased risk with prolonged use of mechanical ventilation using an endotracheal or tracheostomy tube for 12–200 days.2 The most common cause of acquired nonmalignant TEF is intubation, due to a cuff-related tracheal injury. The size of the post-intubation fistula may be 0.3–5 cm. Cuff pressure exceeding 30 mm Hg reduces mucosal capillary circulation and results in tracheal necrosis, especially with a rigid nasogastric tube in place.1–4 Other predisposing factors include poor nutrition, infection, and steroid use. Diagnosis is usually made during mechanical ventilation, with complications such as pulmonary infection and even death.1,3 Abdominal distention secondary to collection of air in the stomach is usually noted on physical examination. Panendoscopy or bronchoscopy are the best diagnostic tools.1–3
Management of TEF is variable. Generally, repair should be delayed until weaning from mechanical ventilation, although some incidences of the patient remaining permanently on mechanical ventilation have been reported.1,5,6 Recently, tracheostomy, gastrostomy, and jejunostomy prior to repair of the fistula have been suggested.1,3,5 The tracheostomy tube cuff should be placed distal to the fistula to prevent pulmonary contamination, with gastrostomy for gastric decompression and jejunostomy for enteral nutrition. Elective 1-stage repair, including simple diversion and closure of the fistula and strap muscle interposition, can be carried out later.1,5 Once extensive damage to the trachea is noted, a 1-stage anterior approach for segmental tracheal resection with primary reconstruction and esophageal closure has been suggested. If tracheal damage is limited, it is recommended that the fistula is divided and the esophageal defect closed with pedicled flaps of strap or intercostal muscle between the trachea and esophagus for reinforcement and direct repair of the esophageal defect. One suggestion was to leave the tracheal lesion alone.4 Other reports have recommended use of selective esophageal diversion, a radial forearm fascial free flap, or esophageal stents.7,8 Esophageal stenting caused no complication or mortality, but it provided only temporary closure of the fistula.7 Predictably, many complications have been described after TEF repair, including tracheal stenosis (2.5%–22%), pneumonia, recurrent fistula (7.3%–11.4%), and esophageal anastomosis leakage (10%);2–5 the overall complication rate is 25%–50%, and surgical mortality is 10%–18.9%.1,2,5 If severe pulmonary infection arises in patients on prolonged mechanical ventilation, TEF should be considered, and further diagnostic tests should be performed. Early diagnosis and timely repair produced excellent results in this case.
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REFERENCES
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ABSTRACT
INTRODUCTION
