We present the case of a 20 months old boy with developmental delay and chromosomal abnormality, who presented with a history of chronic aspiration. He was found to have a laryngeal cleft, which was injected with Prolaryn, then formally repaired, twice. Despite an initial a negative swallow study, the patient had persistent aspiration. A repeat direct laryngoscopy and bronchoscopy finally revealed the presence of an H-type tracheoesophageal fistula (TEF). We describe here the steps of the surgical repair of an H-type tracheoesophageal fistula.
A direct laryngoscopy and bronchoscopy was initially performed. The fistula was identified again at the mid-portion of the posterior membranous trachea. A 3 French Fogerty catheter was passed through the opening. The patient was intubated. A flexible gastro-esophageal endoscopy was performed and the catheter was seen entering the esophagus. The catheter was grasped and taken out the mouth. This catheter would help with easier identification of the fistulous tract during the repair, and may possibly avoid a sternotomy by pulling the tract upwards. A left-sided supra-clavicular incision was performed. Dissection was carried through the sub-cutaneous tissues. Sub-platysmal flaps were raised. The sternocleidomastoid muscle and as well as the straps were retracted laterally. The recurrent laryngeal nerve along the right side was identified and preserved. The trachea and the esophagus were then traced distally. The tracheal esophageal groove was identified with separation of the esophagus from the trachea using gentle blunt dissection. With traction on the Fogarty catheter, the fistulous tract was identified. Using a right angle, the tract was then encircled with a vessel loop. 4-0 Vicryl stay sutures were placed above and below the fistula on the esophagus. The Fogarty catheter was then removed. The tract was transected with electrocautery. The esophagus was repaired with interrupted 4-0 Vicryl sutures. The membranous portion of the trachea was then repaired using interrupted 5-0 PDS sutures. Both repairs were tension-free. Saline was introduced into the wound and the lungs were inflated to a pressure of 30 cm of water with no evidence of air leak from the tracheal repair. The right strap muscles were then mobilized and transected cranially. Evicel was then placed over the tracheal and esophageal suture lines. The strap muscle flap was then rotated and interposed between the tracheal and esophageal suture lines, in a tension-free fashion. The neck wound closed in a regular fashion.
Evidence of tracheoesophageal fistula either through esophagram, or direct laryngoscopy and bronchoscopy/esophagoscopy, in a patient with chronic aspiration.
Poor surgical candidacy
Patient laid supine. After DLB and GI endoscopy, the patient is prepped and draped from the mentum to the upper chest. A shoulder roll is placed. Oral cavity should remain accessible for possible tracheoscopy, and for the removal of the Fogerty catheter when the fistula is isolated and ready to be divided.
1. CXR: gastric distention may be suggestive. 2. Swallow study/esophagram: very likely to miss H-type TEF, due to oblique orientation of the fistulous tract. 3. Tube injection esophagram: while in prone position, contrast material is inected in mid-esophagus through nasogastric tube. More likely to identify H-type fistula than regular esophagram. 4. Bronchoscopy/esophagoscopy. Fistula may very sublte and could also be missed during tracheoscopy.
Most H-type fistulas at or above level of T2 may be resected through a trans-cervical approach.
Short recovery. High success rate. Trans-cervical approach may not be adequate for low fistulas.
Wound infection. Bleeding, hematoma formation. Failure/leak.
No conflicts of interest to disclose.
Dr. Adam Vogel Dr. Rachel Georgopoulos
1. J.T.Brookes,M.C.Smith,R.J.Smith,N.M.Bauman,J.M.Manaligod,A.D.Sandler,H- type congenital tracheoesophageal fistula: University Of Iowa experience 1985 to 2005, Ann. Otol. Rhinol. Laryngol. 116 (5) (2007) 363–368 2. D.C. Crabbe, Isolated tracheo-oesophageal fistula, Paediatr. Respir. Rev. 4 (1) (2003) 74–78. 3. F. Parolini et al. Cervical/thoracotomic/thoracoscopic approaches for congenital H-type tracheoesophageal fistulas: a systematic review. International journal of pediatric otorhinolaryngology. 78 (2014). 985-989.