Category Archives: Tracheoesophageal Fistula

The approach of esophageal exclusion illustrated in this report allows total transcervical control of the fistula. An upper sternal split can be easily accomplished through this approach to facilitate control of the distal esophagus when necessary. This illustration depicts the completed cervical esophageal exclusion which creates a compact new posterior wall of trachea for the ventilator-dependent patient (Fig 3). Access to the gastrointestinal tract can then be accomplished with total fistula control achieved before laparotomy. The potential complication of further abdominal distention and aspiration of gastrointestinal contents through the lower end of tracheoesophageal fistula is averted. Stamm gastrostomy was performed for initial gastrointestinal decompression and subsequent access for enteral alimentation. Although we routinely perform a jejunostomy when prolonged gastric decompression is necessary, we have not found it necessary with this technique when the esophagus is proximally excluded. (more…)

Laparotomy, gastrostomy and gastric drainage procedure follow. This extensive operation is not likely to be tolerated by many of these severely ill patients. Secondly, few institutions are presently equipped with the iron lung he used to ventilate without positive pressure trauma to the precarious tracheal repair. Mediastinal tracheostomy is also a formidable procedure involving resection of manubrium and the medial third of the clavicles and first and second ribs to allow exposure and control of the lower trachea. This procedure may still be required on rare occasion to achieve airway control and adequate ventilation in difficult cases of tracheoesophageal fistula. (more…)

Utley et al advocated cervical and transabdominal exclusion of the esophagus for the management of the giant tracheoesophageal fistula. Finally, Orringer and Sloan described the use of mediastinal tracheostomy to manage similarly difficult tracheal problems when ventilation is otherwise impossible. Division of the tracheoesophageal fistula, resection of the malatic trachea, and primary repair of trachea and esophagus would appear to be the most desirable management option. Grillo et al have cautioned that this approach should only be applied to the patient who can be immediately extubated after repair. Postoperative endotracheal intubation significantly increases the likelihood of repair disruption or recurrence of the tracheoesophageal pathology. These primary repair prerequisites could not be met in this patients case. (more…)

The predisposing factors to endotracheal tube-induced tracheoesophageal fistula described by Cooper and Grillo were all present in this case. This patient required prolonged positive pressure ventilation and an indwelling nasogastric tube was concomitantly required to provide enteral alimen- tation. Furthermore, the endotracheal tube cuff required progressively higher pressures to maintain a ventilatory seal as a result of deteriorating pulmonary function. The chronic nature of this fistulous process is characterized by the lack of subcutaneous emphysema and the finding of worsening pulmonary secretions, intermittent abdominal gaseous distention and deterioration in pulmonary function over the weeks preceding this admission. (more…)

Staple division was performed above and below the fistula avoiding disruption of the inflammatory wall of the fistula (Fig 2). This maneuver created a new back wall of trachea and restored a closed ventilatory circuit with minimal dead space. Tube pharyngostomy drainage was accomplished by transoral localization of the superior pharyngeal recess lateral to the larynx with the aid of a large right-angled surgical clamp. A cervical cut down was then made at a point above the superior cornu of the thyroid cartilage over the site of transoral pressure applied by the instrument. A 20 Fr mushroom catheter was then pulled through the incised opening into the pharynx. Stamm gastrostomy was then performed. (more…)

A primary bacterial pneumonia was suspected and intravenous antibiotics were employed for two weeks. A nasogastric tube was maintained after this septic episode to provide enteral alimentation due to poor oral intake and intermittent abdominal gaseous distention. (more…)

Ventilator-dependent patients developing giant tracheoesophageal fistulae present formidable management problems. We describe a method of cervical esophageal exclusion that can expediently control the tracheoesophageal fistula and restore adequate ventilation for such critically ill patients. (more…)